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Inspection visit

Inspection

SALINE CARE NURSING & REHABCMS #14613411 citations on this visit
11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R96's facility Face Sheet with a print date of 1/27/23 documents R96 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, anxiety disorder, and nutritional deficiency. Residents Affected - Few R96's MDS (Minimum Data Set) dated 8/19/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R96 is cognitively intact. R96's current Care Plan dated 8/19/22 documents a focus area of At risk for fluid imbalance/weight loss. This same care plan includes the following interventions, weights as ordered (8/19/22), two butters to hot vegetables at lunch and supper (8/23/22), whole milk with meals (11/9/22), house shakes with ice cream at 10am, 2pm, and 6pm (11/9/22), add ice cream to lunch and supper (11/9/22), double portions at meals (11/9/22), Boost drink (11/9/22), mirtazapine as ordered for appetite (1/4/23). R96's progress notes documents on 11/26/22, RD (Registered Dietitian) QUARTERLY REVIEW: HT (height): 68, WT (weight)/CBW (calculated body weight): 121.5# (pounds), BMI (Body Mass Index): 18.5 noted resident for quarterly nutritional review and at this time with dx (diagnosis) of pancreatic cancer w/ s/p (with status post) wipple procedure, COPD (chronic obstructive pulmonary disease), anxiety disorder, depression, HTN (hypertension). medications include: selenium, venlafaxine, bupropion, and others. currently on po (oral) diet plan of regular with thin liquids, whole milk at meals, ice cream at lunch and supper, 2 pats butter to hot vegetables at lunch and supper, double portions at meals along with house shakes with ice cream at 10a/2p/8p. intakes of meals currently 50-75% with fluids around 480 ml (milliliter). noted as of 11/9 tube for feeding was removed. resident wt is to be monitored weekly. at this time wts are showing progressive gain since removal of tube from 116.2# on 11/9 to present wt of 121.5#. no skin or lab concerns reported. also informed that daughter provides resident boost shakes and other snacks for her to keep in her room . at this time no change in diet plan. continue with weekly wts and refer to RD as needed. R96's Progress Notes dated 12/08/22 documents, Wound and weight meeting held today. Current weight is 120.9 which is a 1 lb gain from last weight. Current diet is regular with whole milk at meals, ice cream with lunch and supper and health shakes at snack time three times daily. She eats meals in her room independently. Family has provided snacks to keep in her room. She has recently started PT (Physical Therapy) and is more physically active. She will remain on weekly weight monitoring at this time. (Name of physician and family member) are aware of current weight, diet, and treatment plan. R96's progress notes document on 1/25/23 RD WEIGHT REVIEW: Ht (height)-68, Wt (weight)-112.0#, BMI- 17.03. Resident is showing significant weight loss of 7.9% x3 months (121.6# on 10/10) and 7.4% x1 month (120.9# on 12/5). Resident's PMH (past medical history) includes pancreatic cancer s/p wipple procedure, COPD, anxiety disorder, depression, HTN. Hx (history) of J-tube for supplemental tube (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 14 Event ID: 146134 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692 Level of Harm - Actual harm Residents Affected - Few feedings- removed 11/9 due to consistent tolerance of PO (oral) diet . No wounds/skin issues. (R96) continues on regular diet as tolerated with thin liquids. She (R96) feeds herself, typically eats in her room and meal intakes vary with average 25-75%- best at supper. She (R96) has reported a poor appetite. She is receiving a variety of supplements and supplemental foods to support her weight. Current orders: whole milk at meals, ice cream at lunch and supper, 2 pats butter to hot vegetables at lunch and supper, double portions at meals, and house shakes with ice cream at 10a/2p/8p. In addition, her daughter brings in snacks and Boost shakes for resident to keep in her room. Due to resident's weight loss and report of poor appetite, she was started on Mirtazapine on 1/4. She feels it is starting to help her feel more hungry and her intakes are showing some improvement. Feel that current nutrition plan is appropriate to support resident's weight, especially with initiation of appetite stimulant. Continue to monitor weights and intakes; RD will follow routinely but please consult as needed. R96's untitled weight report printed 1/27/23 includes the following weights, 8/21/22- 119.4 lbs. (pounds), 9/5/22- 118.0 lbs., 10/04/22 - 120.6 lbs., 11/07/22- 120.2 lbs., 12/27/22 - 113.2 lbs., 1/11/23 - 112.0 lbs., and 1/25/23 - 114.0 lbs. R96's Vital Signs Grid with a print date of 1/31/23 include the following weights, 11/14/22 - 118.9 lbs., 11/26/22 - 121.5 lbs., 11/28/22- 119.9 lbs., 12/05/22 - 120.9 lbs., 12/10/22 - 120.8 lbs., 12/17/22 - 115.3 lbs., 1/2/23 - 112 lbs., 1/11/23 - 112 lbs., 1/29/23 117 lbs. This indicates R96 had a weight loss of 7 pounds (5.8%) from 11/07/22 to 12/27/22 and weight gain of 5 pounds (4.09%) from 1/11/23 to 1/29/23. On 01/24/23 at 9:30 AM, R96 was observed sitting on the side of her bed with a meal tray on her bedside table. R96's tray had partially eaten scrambled eggs and a whole piece of sausage. R96's meal tray also had a bowl of mostly eaten dry cereal. There was a small cup of thick milk shake type drink on R96's tray. There were no other glasses located on R96's meal tray or bedside table. R96 stated she had weight loss, but they had started her on an appetite stimulant. When asked if she preferred to eat her cereal dry without milk, R96 stated she doesn't always get served milk and sometimes she has to ask for it. R96 stated if she asks for it the staff will say they will get it and then never come back. R96 stated she was not served any liquids with this meal other than the shake type drink. On 01/24/23 at 12:59 PM, R96 was served chicken, rice, broccoli with cheese, oranges, and tea. There was no milk on R96's tray. R96 asked for milk and unknown staff returned with a glass of milk. There was no ice cream observed on R96's meal tray. On 01/27/23 at 08:30 AM, R96 was observed sitting on the edge of her bed with a partially eaten breakfast tray in front of her. R96 was eating dry cereal with no milk. There was an empty glass observed on R96's meal tray that appeared to have had milk in it. When asked if she was served milk R96 stated she was but she had drunk it, since she was thirsty. R96 stated they had forgotten to bring her milk at supper on 1/26/23. When asked if she would like milk for her cereal R96 stated she would. This surveyor reported to the nursing staff passing meal trays R96 would like some milk for her cereal. R96's undated meal ticket documents R96 is to be served a regular diet with 2 pats butter to vegetable (lunch and supper), double portions to meals. Under Notes the same meal ticket documents, Send ice cream with empty glass, whole milk, 2 pats of butter on hot vegetables, double portions, whole milk all meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692 Level of Harm - Actual harm Residents Affected - Few R96's Physician Orders dated 01/2023 includes the following dietary orders, 8/20/22- regular diet as tolerated, 8/23/22- whole milk with meals, 11/09/22- add ice cream to lunch and supper, and mirtazapine 15 milligrams once daily. On 01/26/23 at 3:42 PM, when asked why R96 was not served milk and/or ice cream, V1 (Administrator) stated, I don't know. I didn't serve her meals. When asked if she would expect R96 to be served ice cream and milk as recommended by the dietitian V1 stated, It should have been served. On 01/26/23 at 3:08 PM, V4 (Dietitian) stated R96 is to have whole milk served at all meals. V4 stated R96 is to have ice cream served at lunch and supper and then a health shake with ice cream at 10 AM, 2:00 PM, and 6:00 PM. This surveyor reviewed with V4 observations of breakfast on 1/24/23 with no milk served to R96 and lunch on 1/24/23 when R96 had to ask for milk and was not served ice cream. When asked if not getting her supplements as recommended would have an impact on R96's weight, V4 stated the supplements would provide extra calories but it could be a combination of factors causing the weight loss. V4 stated they would have to investigate further to determine if that was causing the weight loss. On this same date at this same time, V5 (Dietitian) stated she was aware of R96's weight loss and that an appetite stimulant had been started. V5 stated R96's weights were trending up since starting the stimulant. 01/31/23 at 9:28 AM, V1 (Administrator) stated when she spoke with R96 in December 2022, related to her weight loss, R96 reported she didn't have an appetite. V1 stated they contacted R96's physician and he gave them an order for an appetite stimulant that wasn't covered by R96's insurance. V1 stated then they contacted the physician a second time for a different appetite stimulant. V1 stated that is when mirtazapine was ordered. On 1/26/23 at 12:40pm, V6 (CNA) said that when they weigh a resident, they use the wheelchair scale. If a resident is able to walk they stand on it, if not they push the resident in the wheelchair on the scale. V6 said they have to subtract the weight of the wheelchair after weighing a resident in a wheelchair. Based on observation, interview, and record review the facility failed to consistently and accurately weigh residents and ensure residents with a history of weight loss received ordered supplements with meals for 4 of 13 residents (R70, R90, R94, and R96) reviewed for nutrition status in a sample of 49. This failure resulted in R70 who had a history of severe weight loss continuing to have an 10 % (significant weight loss) in the past six months. Findings include: 1. R70's face sheet documented an admission date of 11/12/21 and diagnoses including: Alzheimer's disease, schizophrenia, generalized anxiety disorder. R70's 12/9/22 MDS (Minimum Data Set) documented a BIMS (Brief Interview for Mental Status) score of 2, indicating severe cognitive impairment. R70's Physician Orders documented: 8/23/22 order for whole milk at all meals, 8/23/22 order for add 2 butters to hot vegetables at lunch and supper, 12/31/22 order for give ice cream or sherbet at lunch and supper. R70's nutritional risk care plan start date 11/12/21 documented interventions: 8/23/22 whole milk served at all meals, 6/1/22 give ice cream or sherbet at lunch and supper, 8/23/22 add butters to hot vegetables at lunch and supper. R70's unnamed weight log printed 1/31/23 documented weights as: 2/21/22 165.0 pounds, 3/9/22 165.4 pounds, 4/10/22 154.4 pounds, 5/9/22 154.2 pounds, 6/10/22 149.8 pounds, 7/7/22 151.2 pounds, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692 Level of Harm - Actual harm 8/15/22 148.7 pounds, 8/29/22 149.2 pounds, 9/5/22 150.6 pounds, 10/3/22 146.5 pounds, 10/10/22 144.4 pounds, 10/17/22 143.9 pounds, 10/25/22 144.9 pounds, 10/31/22 142.6 pounds, 12/10/22 140 pounds, 1/11/23 139.4 pounds, 1/29/23 136 pounds. This represents an approximate 8.54% (Significant weight loss) in the previous six months. Residents Affected - Few R70's 6/29/22 progress note made by V4 Registered Dietitian (RD) documented in part .RD Wt (Weight) Note: Wt: 6/10 149.8# . resident is showing a wt loss of 9.4% in 3 months (3/9 165.4#), loss of 13.7% in 6 months (121/5 sic. (12/5) 173.6#) . remains on regular diet with ice cream/ sherbet at lunch and supper . suggest to change milk served to whole and add 2 butters to hot vegetables at lunch and supper for added calories . R70's 8/21/22 progress note made by V4 (RD) documented in part .RD Wt Note: . WT: 8/15 148.7# . resident showing loss of 10% in 6 months (2/21 165#) . remains on diet plan of regular with ice cream or sherbet at lunch and supper . at this time will suggest to please add weekly wts to monitor weight fluctuations and change milk served to whole and add 2 butters to hot vegetables at lunch and supper for added calories R70's 1/26/23 progress note made by V5 (RD) documented in part . RD Weight Review . WT- 139.4# . Resident is showing a gradual weight loss over the past 6 months (148.7# on 8/15/) . (R70) does have pertinent dx (diagnosis) of Alzheimer's and Schizophrenia, on Clonazepam and Risperidone which can affect intakes and weights . She is confused at all times, often wandering all around facility which can also contribute to weight decline (increase energy expenditure) .supplements/ supplemental foods in place to add extra calories. Current order: whole milk at all meals, 2 butters to hot vegetables at lunch and supper . ice cream or sherbet at lunch and supper . On 1/24/23 at 1:07 PM, R70 was sitting in the dining room and was served a noon time meal tray with chicken, rice, broccoli and cheese, tea, coffee, and pureed fruit. No butter or ice cream was served to R70. R70's ice cream was observed to be in a bag at the serving station with R70's name on it. On 1/26/23 at 1:16 PM, R70 was sitting in the dining room and was served the noon time meal consisting of Meat loaf, hashbrowns, green beans, dinner roll, apple sauce, lemonade, tea, ice cream, and one pat of butter open by her plate but not used. No milk was served to R70 and no butter was put on her hot vegetables. R70's 1/26/23 meal ticket documented in part ice cream or sherbet; 2 pats butter to hot vegetables . whole milk . On 1/26/23 10:58 AM, V5 (RD) said if R70 did not receive the two pats of butter to hot vegetables, ice cream, and whole milk R70 would not have received approximately 300 calories. V5 said if staff are not serving all the ordered items to residents it could contribute to weight loss. V5 said R70 has had a gradual weight loss over a period of several months. V5 said she expected all staff to follow the resident's diet orders. 2. R94's face sheet documented an admission date of 7/27/22 and diagnoses including: memory deficit following unspecify cerebrovascular disease, secondary hypertension, hyperlipidemia muscle weakness, vitamin B12 deficiency anemia. R94's 10/28/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. R94's Physician Orders documented a 1/25/23 order for 2 pats of butter to vegetables at noon and supper meals. R94's Nutritional Risk care plan with a start date of 7/27/22 documented interventions: 7/27/22 diet as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692 Level of Harm - Actual harm Residents Affected - Few R94's unnamed weight log printed 1/31/23 documented: 7/27/22 185 pounds, 8/1/22 188.4 pounds, 9/5/22 191.2 pounds, 10/10/22 184.1 pounds, 11/7/22 184.9 pounds, 12/10/22 182 pounds, 1/12/23 165.8 pounds, 1/25/23 164 pounds. R94's 1/26/23 meal ticket documented in part . 1ea (each)/ 1 tsp (teaspoon) - Dinner Roll/ Margarine . 2 pats of butter on hot vegetable . On 1/26/23 at 1:23 PM, R94's noon time meal of meat loaf, hash browns, green beans, a dinner roll, and applesauce was delivered to his room with only one pat of butter on his tray. On 1/26/23 at 1:53 PM, V7 Certified Nurse's Assistant (CNA) reviewed R94's 1/26/23 noon meal ticket with the surveyor and said R94 should have received two butters on his noon time meal tray. On 1/26/23 at 3:40 PM, V5 (RD) said on the 1/26/23 noon time meal R94 should have received three pats of butter (1 for the dinner roll and 2 on the hot vegetables.) On 1/27/23 at 2:12 PM, V4 (RD) said the intervention of adding 2 pats of butter is ensured by watching meal service. V4 said the staff member delivering the resident's tray is responsible for ensuring residents with an order for 2 pats of butter on hot vegetables has the butter delivered. On 1/31/23 at 12:06 PM, V5 (RD) was asked why there was no RD review note when R94 had a 7.1 pound weight loss (3.7%) from 9/5/22 at 191.2 pounds to 10/10/22 at 184.1 pounds V5 responded she did not know why there was no RD review. V5 said the RD will run a weight report to review all monthly and weekly weights in the facility and any changes will be captured in that report. V5 said she was not familiar with R94 and if weight fluctuations were normal and if a 3.7% loss in a month would require a RD review. R94's 1/25/23 progress note from V5 (RD) documented in part .RD Weight & Quarterly Review . Wt (weight) 165.8# (pounds) (1/12) . Resident is showing significant weight loss of 10.4% x 6 months (185# on 7/27) and 9.9% x3 months (184.1# on 10/10). Staff shared with RD an updated wt from today (1/25)159.6# which represents some further weight loss . Due to weight loss, would recommend starting . adding 2 pats of butter to hot vegetable sides at lunch and supper for extra calories. Monitor weights and intakes: Refer to RD as needed. R94's Progress noted dated 1/26/23 at 7:02 AM documented in part .RD reviewed weights for (R94) and suggested added 2 pats of butter to hot vegetables and health shake at Breakfast. Dr. (Doctor) notified and approved new orders. Tray card and snack list has been updated . The facility's October 2017 Therapeutic Diet policy documented in part . 2. A therapeutic diet must be prescribed by the resident's attending physician (or non- physician provider). The attending physician may delegate this task to a registered or licensed dietitian . 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet . 3. R76's face sheet documents a date of admission to the facility on 5/5/21. This same face sheet documents R76 has diagnoses including vascular dementia with behavioral disturbance, other schizophrenia, and anxiety disorder. R76's MDS (Minimum Data Set) dated 1/13/23 documents a BIMS (Brief Interview of Mental Status) score of 99, indicating R76 has severe cognitive impairment. Section G of the same MDS notes that R76's self-performance for eating is extensive assistance and support given is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692 Level of Harm - Actual harm one- person physical assist. The same MDS notes that for transfers, walk in room, walk in corridor, locomotion on and off unit, R76's support provided is extensive assistance and one-person physical assist. R76's MDS also notes that she uses a wheelchair as a mobility device and her balance during transitions and walking is not steady, only able to stabilize with staff assistance. Residents Affected - Few On 1/31/23, V1 (Administrator) said that R76 uses a wheelchair and requires staff assistance but R76 is also impulsive and will get up without asking for assistance. V1 said that R76 has an unsteady gait. R76's care plan with a start date of 5/5/21 documents a focus area of Nutritional Risk, with history of refusing some meals, diabetic, low Vitamin D. The goal listed on the same care plan is to maintain or improve weight and health status. Some of the interventions listed on R76's care plan include diet as ordered, encourage oral intake, provide non-distracting eating environment as needed, weights as ordered. R76's Physician Orders List documents an order dated 5/6/21 for LCS (low concentrated sweets), NAS (No added salt), mechanical soft diet. This document also notes an order dated 6/19/21 for weekly weights. On 1/32/23 at 9:35am, V1 said that the 6/19/21 order for weekly weights should have been discontinued and the original order should have said weekly weights times 4, then monthly, and then only back to weekly when the RD (Registered Dietician) recommends them. V1 said this is how they do all admissions. The same physician order list documents an order on 12/16/22 for whole milk with meals, add ice cream to supper and on 1/26/23 to add 2 pats of butter with hot vegetables, health shakes BID (twice daily) between meals. R76's Vital Sign Grid documents that on 1/29/22, R76 weighed 129.6 pounds (lbs) and approximately one year later on 1/25/23, R76 weighed 118 lbs. R76 was sometimes being weighed weekly and sometimes monthly during this time frame. R76's vital sign grid documents the following additional weights: 01/08/22: 129.2 lbs 01/11/22: 140.2 lbs 01/15/22: 126.4 lbs 01/29/22: 129.6 lbs 05/09/22: 131 lbs 06/10/22: 119 lbs 06/23/22: 138 lbs 07/07/22: 134.8 lbs 08/15/22: 149.1 lbs 10/29/22: 147.8 lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692 11/07/22: 123.8 lbs Level of Harm - Actual harm 11/19/22: 126.9 lbs Residents Affected - Few 12/10/22: 128.3 lbs 12/26/22: 120.1 lbs 12/31/22: 116.8 lbs 01/11/23: 116 lbs 01/25/23: 118 lbs 01/29/23: 127 lbs R76's progress note written by V4 (Registered Dietician/RD) documents on 10/29/22, RD Quarterly Nutritional Review: HT (height) 63, WT (weight) 10/10 147.8#, BMI (Body mass index) 26.3 noted that HTN (hypertension), anxiety disorder, T2DM (type 2 diabetes mellitus) schizophrenia, h/o (history of) UTI (urinary tract infection) noted with medication of: Aricept, HCTZ (hydrochlorothiazide), quetiapine, ativan, levothyroxine, escitalopram, melatonin, pravastatin, metformin and others, is tolerating a diet plan of NAS (no added salt), LCS (low concentrated sweets) mechanical soft with intakes reported around 50-100%. Resident is reported to eat in the main dining area and feeds herself. Wts (weights) are showing gradual increase in the last 6 months and currently stabilizing round 147-149#, Present wt range is within desirable per BMI . at this time diet plan remains appropriate and no changes requested. Refer to RD as needed. R76's Vital Sign Grid documents the next weights after the 10/29/22 RD Quarterly Nutritional Review were on 11/7/22 (123.8 lbs) and 11/19/22 (126.9 lbs). This shows a 24 pound weight loss in 9 days, from 147.8 lbs on 10/29/22 to 123.8 lbs on 11/07/22. R76's progress note documents on 11/25/22 RD wound/wt Review: HT: 63, WT/CBW (weight/current body weight): 126.9#, BMI: 22.5 resident is reviewed related to showing significant wt loss 14.1% in last month (10/10 147.8#) and loss of 14.9% in the last 3 months (8/15 149.1), .noted wts had been fluctuating 130-150# range and at this time noted in upper 120# area diet plan remains on LCS, NAS, mechanical soft and intakes are reported around 100% of meals and fluids around 480ml (milliliters) at this time will request to please recheck wt and place resident on weekly weights. No change in diet plan at this time with intakes noted .monitor weekly wts and refer to RD as needed. There is no evidence to show that R76's weight was rechecked at this time. R76's weight grid documents that the next weight after the 11/25/22 recommendation to re-weigh her was 126.2 lbs on 11/30/22. There are no weights documented again until 12/10/22. R76's progress note by V4 dated 12/15/22 titled RD WT note documents HT: 63, WT: 12/10 128.32#, BMI: 22.8 noted that resident is showing wt loss in the last 3 months of 13.9% (8/15 149.1#) .noted diet plan of mechanical soft LCS, NAS and intakes are around 100% of meals .at this time will request to please add to weekly wts to monitor and please change milk served to whole and add ice cream to supper for added calories, continue to monitor intakes and wts and refer to RD as needed. R76's weight grid documents the next weights are as follows: 12/26/22 - 120.1 lbs, 12/31/22 - 116.8 lbs, 1/11/23 - 116 lbs and on 1/25/23 118 lbs. R76's progress note by V4 documents on 1/25/23 RD weight/Wound & Quarterly Review: HT: 63, Wt: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692 Level of Harm - Actual harm Residents Affected - Few 116.0#, BMI: 20.55 Resident showing significant weight loss of 13.9% x(times) 6 months (134.8# on 7/7) and 21.5% x3 months (147.8# on 1010/22) .resident remains on LCS, Mech soft diet with thin liquids. She feeds herself with meal intakes averaging 75-100% per record. For extra calories, resident receives whole milk at meals and ice cream at supper. Per discussion with staff, resident is very active. Self propels in wheelchair all around facility. Amount of activity is likely contributing to weight decline and increasing R76's needs .would recommend adding extra 2 pats butter to hot vegetable sides at lunch and supper and start health shake as snack between meals at 10am & 2pm. Continue rest of nutrition plan monitoring weights and intakes. RD will follow routinely but please consult as needed. R76's diet card dated 1/26/23 documents LCS (low concentrated sweets), dental soft (mechanical soft), thin liquids. The same diet card also notes milk - 4 fluid ounces (oz), #8 dip - Ground Meatloaf w/ (with) gravy. #8 dip/2oz gvy (gravy) - Mashed potatoes and gravy, 4oz spdl (spoodle) - soft country cooked country chpd (chopped) [NAME] Beans - No bacon, 1 ea (each)/1 tsp (teaspoon) - Dinner Roll/margarine, 4oz spdl cinnamon peaches, 1 cup diet beverage. Additional notes on R76's diet card list to add ice cream, 2 pats butter to hot vegetable, whole milk. On 1/26/23 at 12:15pm, R76 was noted to propel herself to the dining table and remained at the table until her meal was served at 12:30pm. At 12:30pm, R76's meal tray was noted to have cut up meatloaf with no gravy, mashed potatoes with no gravy, green beans without 2 pats of butter, and no dinner roll with margarine. R76 was observed at this time to consume 100% of her meal. On 1/26/23 at 12:30pm, when questioned about R76's diet card, V7 (CNA/Certified Nurse Assistant) stated that they were out of gravy and then went to get 2 pats of butter and put this on R76's vegetables. No dinner roll with margarine was ever brought back to R76. On 1/26/23 at 12:35pm, V6 (CNA) said they frequently do not go by the menu. She stated if they are out of something, they substitute it. V6 also said that R76 almost always consumes 100% of her meals and they document her intakes with every meal. On 1/26/23 at 11:17am, V1 (Administrator) stated that the process for weighing residents is that the weekly weights have to be done by Sunday. V1 said that the weights are then sent to the nursing director, and they are reviewed. V1 said if there are any weights that are really off, they have staff go re-weigh them. V1 said the problem with the weights being off is that V4 (Registered Dietician) thought she would be helpful and enter them without sending them to the nursing director, and that lead to missing weight loss and residents not getting re-weighed. On 1/27/23 at 2:12pm, V4 said she can't explain (R76's) 24-pound weight loss in 1 week. V4 said if there is a weight really off, she would ask for them (residents) to be re-weighed. V4 said she would not know if weekly weights were not being done usually until the next month when she comes back. V4 said in her notes she says refer to RD if needed and therefore would expect the facility to let her know of the weight. V4 said there are a lot of variances with being weighed .type of scale, location, whether they have had a bowel movement, the time of day. V4 said she looks at a trend with weights and if she notices a weight off, she would ask for a re-weigh and if not she would make a recommendation. On 1/31/23 at 8:35am, V1 stated that R76 is eating all the time and gets a lot of snacks. V1 said there is no way R76 lost that much weight in a week (in reference to the 24- pound loss from 10/29/22 to 11/7/22) and should have been re-weighed. V1 stated that they use a wheelchair scale on side 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692 It can also be used as a standing scale. V1 said she believes the problem with (R76's) big weight loss in 1 week is due to staff not subtracting the wheelchair when they weigh residents. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to allow a resident to make choices pertaining to their diet needs by providing requested food items for 1 out of 13 (R42) residents reviewed for nutrition in a sample of 49. Findings include: R42's facility Face Sheet with a print date of 1/26/23 documents R42 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, hypertension, diabetes, heart disease, major depressive disorder, and generalized anxiety disorder. R42's MDS (Minimum Data Set) dated 7/11/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R42 is cognitively intact. R42's Care Plan under At Risk for Complications From Diabetes : Baseline CP (Care Plan) Nutrition with a start date of 7/12/22 documents interventions as: Current diet: See POS (Physician Order Sheet), Monitor blood sugar and monitor for signs and symptoms of hyper/hypoglycemia, Monitor meal percentage intake, and offer bedtime snack. R42's Physician Order List documented a 7/12/22 diet order for regular consistency/ consistent carb diabetic diet with snacks at 10 AM, 2 PM, and 10 PM. R42's Departments Notes dated 1/2/23 at 6:42 PM by V15 Licensed Practical Nurse (LPN) documents, Resident (R42) walked up to where they were serving out food with his plate. One on one with (R42) he could not go up where they were serving. (R42) told this writer to shut up. (R42) sit down (sic). Asked (R42's) nurse if he could have extras. She said his (R42's) blood sugars had been running high at night. They had potatoes and yams (sic). Tried educating (R42) on his diet and DM (diabetes mellitus). (R42) said he didn't care about his sugar. Told him that we did. (R42) asked this writer what my name was. I told him. (R42) said I'm going to tell my daughter. This writer called and updated Admin (administrator) (V1). R42's Departmental Notes dated 1/13/23 at 2:53 PM by V16 Licensed Practical Nurse (LPN) documents, At lunch I observed this resident (R42) tell male peer sitting at this table that if he didn't want his food, he (R42) will take it. Other resident eats slow and stopped eating and handed his nearly full plate to (R42) who scraped off food into his plate. (V16 (LPN)) .went to tell them both that cannot do that, and this resident (R42) started screaming. Screaming and cursing us (sic). I have talked to both residents before about this, but they continue to do the same. On 1/27/23 at 9:07 AM, R42 stated if you ask for more food after the meal rarely do you get anything else. Most of the time they just ignore me. I'm hungry often. I don't know why they can't give me more, they have it right there (meaning the steam table serving area in the dining room). On 1/26/23 at 12:15 PM, V15 (LPN) said on 1/2/23 serving staff came to ask her if R42 could have extra food after R42 had finished his meal tray. V15 said all that was left on the steam table was mashed potatoes and yams. V15 said R42's blood sugar had been running in the 300s and would have to get extra insulin coverage. V15 said she told R42 he could not have any second helping and R42 became angry and started cursing at V15. V15 said if a diabetic resident asks for more food after finishing their meal it would depend on what their blood sugar was if they would be allowed more. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/26/23 at 12:06 PM, V16 (LPN) said if a resident was to ask for second helping after they have eaten their meal facility staff should come ask the nurse if the resident may have more food. V16 stated if they wanted an extra piece of cake and their blood sugar was running high I would say no. I would educate them to substitute a protein. V16 said R42 was alert and oriented, sometimes forgetful, and not delusional. On 1/26/23 at 3:40 PM, V4 Registered Dietitian (RD) said if a resident eats all of their meal and tells staff they are still hungry she expected staff to give them an extra portion as long as it was included on the resident's diet plan. V4 said if the resident is diabetic, carbohydrate intake should be monitored. V4 said a resident should be educated on dietary restrictions, but have the right to choose if they want something. V4 said she did not expect any staff to tell a resident asking for more to eat no may not have something. On 1/27/23 at 2:50 PM this surveyor reviewed with V14 (Physician), R42's request for extra food and high carbohydrate food items that was denied by the facility since R42 was diabetic. V14 stated they could adjust the medications to accommodate R42 eating extra food and/or eating food high in carbohydrates. V14 stated R42's last hemoglobin A1C was 9.4 which is not fabulous but if R42 is hungry they should allow him to eat. V14 stated if they need to adjust the medications they can. The facility's December 2016 Resident Rights policy documented in part . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include resident's rights to: . e. self-determination . bb. Be informed of safety or clinical restrictions or limitations related to care and diets; inform the resident of the best course for their care, ie refusal of treatments, medications, not following diets, etc . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow dietary menu portion sizes for 13 of 13 residents (R4, R10, R19, R27, R48, R52, R55, R57, R63, R71, R73, R76, and R311) reviewed for nutrition out in a sample of 49. Findings Include: On 1/26/23 at 12:32 PM the noon time meal service was started with meat loaf, hash browns, green beans, a dinner roll, and applesauce being served. Residents with puree or mechanical soft diets were served mashed potatoes for substitution for the hash browns. The scoop of mashed potatoes being served appeared to be a very small amount, approximately the scoop size of a golf ball. On 1/26/23 at 1:23 PM, V12 (Dietary Aide) said all the residents who had a pureed or mechanical soft diet were served mashed potatoes. V12 said she was unsure what size scoop was being used to portion out the mashed potatoes. V12 was not able to find the scoop size on the portion scoop. On 1/26/23 at 1:28 PM, V11 (Dietary Manager) identified the scoop used for the mashed potatoes as a #20 scoop. V11 said the #20 scoop measured out 1.7 ounces. V11 said the recipe documented a #8 scoop was supposed to be used. V11 said a #8 scoop measured out 2 ounces. On 1/26/23 at 3:40 PM, V5 Registered Dietitian (RD) said she expected facility staff to follow recipes with correct portion scoops. V5 said a #8 scoop measured out half a cup. The facility's Diet Spreadsheet for 1/26/23 documented a #8 scoop was supposed to be used for the mashed potatoes. On 1/26/23 a list was requested from the facility of all residents who were currently being served a mechanical soft or puree diet for lunch that day. Face sheets and Physician's order sheets were provided for R4, R10, R19, R27, R48, R52, R55, R57, R63, R71, R73, R76, and R311's After a review of the current Physician's Order for January 2023 for R4, R10, R19, R27, R48, R52, R55, R57, R63, R71, R73, R76, and R311's the diet breakdowns were as follows: R10, R48, R52, R55, R57, R63, R71, R73, R76, and R311's were ordered a mechanical soft diet; R4, R19, and R27 were ordered a puree diet. On 1/31/23 at 10:34 AM, V13 (Chief Executive Officer) said the facility was unable to produce a portion scoop size grid because there was not one accessible to staff and there was not one in the facility. According to https://foodbuyingguide.fns.usda.gov/Content/TablesFBG/Table13_FBG.pdf , Table 13: Sizes and Capacities of Scoops documented a #8 scoop as half a cup and a #20 scoop as three and one third tablespoons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure therapeutic diets were followed for 2 of 10 (R44 and R45) residents reviewed for nutrition in the sample of 49. Findings Include: 1. R45's facility Face sheet with a print date of 1/27/23, documents R45 was admitted to the facility on [DATE] with diagnoses that include traumatic brain injury, schizophrenia, cerebral infarction, dementia, heart failure, and anemia. R45's MDS (Minimum Data Set) dated 11/18/22 documents a BIMS (Brief Interview for Mental Status) score of 03, which indicates a severe cognitive impairment. R45's undated Physician Orders List documents the following physician order, Diet upgrade to mechanical soft with ground meat, thin liquids. On 1/26/23 at 12:38 PM, R45 was observed eating the noon meal. R45 was eating a whole piece of meatloaf with ketchup on top of it, mashed potatoes, green beans, dinner rolls, and applesauce. R45 had completed approximately 40% of his meal at this time. R45's meal ticket that was observed laying on the table next to R45's meal tray and documented R45 was to get ground meatloaf with gravy. This surveyor brought to the attention of V3 (Director of Clinical) the discrepancy in R45's meal ticket, and the whole meatloaf with ketchup, R45 was served. V3 took R45's meal tray and replaced it with a meal tray that had meatloaf that was ground with what appeared to be gravy on top of the meatloaf. On 1/26/23 at 3:18 PM, V4 (Dietitian) stated whatever R45's meal ticket documented is the meal R45 should have been served. 2. R44's facility Face Sheet with a print date of 1/26/23 documents R44 was admitted to the facility on [DATE] with diagnoses that include heart failure, diabetes, hypertension, bipolar disorder, generalized anxiety disorder, morbid obesity, and dependence on renal dialysis. R44's MDS (Minimum Data Set) dated 11/30/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R44 is cognitively intact. R44's Physician Orders documented a 11/27/22 order for a renal low concentrated sweets diet. On 1/26/23 at 1:03 PM, R44 was sitting in the dining room and was served meatloaf without ketchup sauce on top, hashbrowns, green beans, and apple sauce. R44 said she was not supposed to have the potatoes and was supposed to receive buttered noodles. R44 said she was on dialysis and was on a renal diet. R44's 1/26/23 meal ticket documented R44 was supposed to receive buttered noodles instead of the hashbrowns served at the noon time meal. On 1/26/23 at 3:40 PM, V4 Registered Dietitian (RD) said a resident on dialysis would be recommended to be placed on a renal diet. V4 said a renal diet would limit protein, phosphorus, potassium, and sodium. V4 said examples of things limited would be potatoes, tomatoes, milk, meat, and oranges. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0808 Level of Harm - Minimal harm or potential for actual harm On 1/31/23 at 12:06 PM, V5 Registered Dietitian (RD) said she expected resident diet orders to be followed. V5 said R44 was aware of what items were supposed to be restricted, but if a confused resident or resident who was unaware of restricted items, they could potentially be eating what was served that was outside of their ordered dietary substitutions. V5 said if a resident on dialysis was eating several meals that were not correctly served with the renal diet substitutions the residents lab values could be affected. Residents Affected - Few The facility's October 2017 Therapeutic Diets policy documented in part .2. A therapeutic diet must be prescribed by residents attending physician . the attending physician may delegate this task to the registered or licensed dietitian as permitted by state law . 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet . The facility's undated Renal Precautions documented in part .1. When Renal Precautions are used as a care planning strategy, the following meal modifications are offered to the resident and with their agreement added the to individuals meal card: . d. Potatoes and potato products are limited to one serving at lunch and/ or supper . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146134 If continuation sheet Page 14 of 14

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Citations

11 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0692SeriousS&S Gactual harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0800GeneralS&S Dpotential for harm

    F800 - Food and nutrition services

    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

  • 0803GeneralS&S Epotential for harm

    F803 - Menus and nutritional adequacy

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  • 0808GeneralS&S Dpotential for harm

    F808 - Therapeutic Diets

    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

  • 0039GeneralS&S Fpotential for harm

    Conduct testing and exercise requirements.

  • 0271GeneralS&S Epotential for harm

    Have exits that are accessible at all times.

  • 0346GeneralS&S Fpotential for harm

    Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  • 0353GeneralS&S Epotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0354GeneralS&S Fpotential for harm

    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  • 0511GeneralS&S Dpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0712GeneralS&S Fpotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

FAQ · About this visit

Common questions about this visit

What happened during the January 31, 2023 survey of SALINE CARE NURSING & REHAB?

This was a inspection survey of SALINE CARE NURSING & REHAB on January 31, 2023. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SALINE CARE NURSING & REHAB on January 31, 2023?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide enough food/fluids to maintain a resident's health."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.