Inspection·April 5, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for 1 (R56) of 2 residents reviewed for advanced directives in the sample of 43. The Findings Include: R56's Facesheet with a print date of [DATE] documents R56 was admitted to the facility on [DATE] with diagnoses that include schizophrenia, anxiety disorder, major depressive disorder, chronic obstructive pulmonary disease, hypothyroidism, benign prostatic hyperplasia, anemia, gastroesophageal reflux disease, and influenza. R56's POLST form dated [DATE] documents under Orders for Patient in Cardiac Arrest, a check mark next to, No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation . On [DATE] at 9:19 AM, a review of R56's electronic health record documents a physician order that indicates R56's POLST states as Full Code. On [DATE] at 12:07 PM, V1 (Administrator) stated R56's Power of Attorney changed R56's status from full code to DNR (do not resuscitate) on [DATE]. V1 stated they changed it everywhere in the electronic health records but they didn't put the new POLST status in R56's physician's orders. R56's undated Physician Orders List with active orders only provided to this surveyor by V1 (Administrator) does not document a physician order related to advance directives. The untitled and undated physician order provided to this surveyor by the facility documents a physician order of Full Code with a start date of [DATE], a discontinue date of [DATE], and a last modified date of [DATE]. On [DATE] at 1:15 PM, V1 stated she discontinued the order after the discrepancy was brought to her attention by this surveyor. The facility Advance Directives Policy dated 12/2016 documents, Advance directives will be respected in accordance with state law and facility policy 19. The Director of Nursing Services or designee will notify the attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has ad ethical or conscientious objection. 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 4 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 04/05/2024 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)