Health 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. Page 1 of 4 146134 146134 04/05/2024 Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946

F 0851 Level of Harm - Potential for minimal harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review the facility failed to accurately report Registered Nurse (RN) hours to the payroll-based journal. This has the potential to affect all 104 residents residing in the facility. Residents Affected - Many Findings Include: Review of Staffing Data Submission Payroll Based Journal (PBJ) found at, https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission and last facilities to submit staffing information - Payroll Based Journal (PBJ). This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy. Review of the facility's PBJ report for Fiscal Year Quarter 1 2024 (October 1 - December 31), documented No RN hours on the following dates: 10/07/23, 10/08/23, 10/22/23, and 12/28/23. Nursing schedules reviewed for RN coverage on 10/7/23, 10/8/23, 10/22/23, and 12/28/23 documented coverage was provided by V1 (Administrator), who was a contracted Registered Nurse at the facility during that time. On 04/05/24 at 10:54 AM, V1 confirmed that she did work the days in question as the Registered Nurse at the facility, although the origination of discrepancy in the PBJ hours reported cannot be determined at this time. The Long Term Care Facility application for Medicare and Medicaid dated 4/2/24, documented 104 residents reside in the facility. 146134 Page 2 of 4 146134 04/05/2024 Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946

F 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 5 of 5 residents (R3, R23, R46, R64, R72) reviewed for room size in a sample of 43. Residents Affected - Some Findings include: An observation on 4/3/24 at approximately 3:14 pm, revealed R23 is in his room alone currently but will have his roommate back after his therapy is completed. It was a smaller sized bedroom with two beds and 2 night stands and had a limited area to move around inside the room. An observation on 4/3/24 at approximately 3:18 pm, revealed R46 was in his room alone with no roommate at this time. It was a smaller sized bedroom with two beds and 1 night stand and a recliner. The room had limited area to move around inside. An observation on 4/3/24 at approximately 3:20 pm, revealed that R64 was in the bedroom alone. It was a smaller sized bedroom with one bed, one recliner and 1 night stand. The room had limited area to move around inside. An observation on 4/3/24 at approximately 3:25 pm, revealed that R72 and R3 were in a room together. It was smaller sized bedroom with 2 beds and 2 night stands. This room had limited area to move around inside. During a tour with the V2 (Maintenance Director) on 4/3/24 at 3:14pm, V2 was asked to measure R3, R23, R46, R64 and R72's bedroom sizes. V2 used the measuring tape to measure the length and width of R3, R23, R46, R64 and R72's room and stated, 12.5 by 12 feet, indicating that the rooms were 150 square (sq.) feet (ft.), or 75 sq. ft. per bed. The measurements did not include the closet and bathroom. During an interview on 4/3/24 at approximately 3:30pm, when asked about the size for two-resident bedrooms, V2 stated that he is unsure of the required square feet for resident rooms and has never measured the rooms before. On 4/2/24 at 2:30pm, V1 (Administrator) stated that Side 2 of the facility (where R3, R23, R46, R64 and R72 reside) has a room size waiver assessment. V1 stated that most of these residents do not have roommates but are still certified for two residents. V1 stated rooms 203-206, 208-209, 211-212, 215-220, 222-227, 229-231, 234-235, 238-239, 241-242, 244-248 are all waivered rooms and don't meet the proper room size. A facility room roster provided by the facility on 4/2/24 and dated 4/1/24, documents that R3, R23, R46, R64 and R72 reside in the rooms observed and measured by V2. Inquiries regarding the size of these rooms during the survey from 04/02/24 to 04/05/24, found no concerns or negative interviews from residents or families of residents who reside in the waivered rooms. During interview, on 04/03/24, R3, R23, R46, R64 and R72 all voiced no concerns with the size of their rooms during interviews. 146134 Page 3 of 4 146134 04/05/2024 Saline Care Nursing & Rehab 120 South Land Street Harrisburg, IL 62946

F 0912 Review of 6 months of Resident Council meeting minutes indicated no concerns related to the size of the rooms. Level of Harm - Potential for minimal harm Residents Affected - Some 146134 Page 4 of 4