Health inspection·March 23, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review the facility failed to prevent employee to resident abuse for one of two residents (R26) reviewed for abuse in the sample of 26. This failure resulted in V3 (CNA/Certified Nursing Assistant) rough handling R26 during cares, resulting in R26 crying and sustaining bruises, a hematoma, and pain to the left arm. Findings include: The facility's Abuse Prevention and Abuse Reporting policy dated 12/2017 documents, Purpose: To assure the prevention of mistreatment, neglect, or abuse of residents or misappropriation of residents' property to the extent it is in the control of the facility. Policy: Residents of this facility will be free from abuse, neglect, or misappropriation of resident property. Every employee who suspects abuse, neglect, or misappropriation of resident property will follow proper abuse investigation and reporting procedures in accordance with state and federal law. Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable through the use of technology. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mistreatment is defined as inappropriate treatment or exploitation of a resident. R26's MDS (Minimum Data Set) Assessments dated 11-13-22 and 2-13-23 document R26 is cognitively intact. R26's Progress Notes dated 1-3-23 at 2:19 PM and signed by V4 (RN/Registered Nurse Supervisor) document, (R26) reported to (V6/CNA/Certified Nursing Assistant) and nurse that other staff member (V3/CNA) was jerking resident around. (R26) showed staff member some bruising on her arm. Notifications made to (V1/Administrator), (V2/Director of Nursing), (V10/Social Service Director), (V12/R26's Power of Attorney), and (V13/R26's Physician). R26's Progress Notes dated 1-4-23 at 11:38 AM and signed by V5 (LPN/Licensed Practical Nurse) documents, (R26) has two circular bruises to mid anterior forearm quarter sized. The bruise that is closer to elbow is swollen slightly presenting a hematoma. Pain when touched with facial grimacing. Resident denies pain when it is not being touched. Another circular bruise to right mid anterior forearm also the size of a quarter. Page 1 of 5 145436 145436 03/23/2023 Apostolic Christian Restmor 1500 Parkside Avenue Morton, IL 61550

F 0600 V3's Termination Checklist dated 1-3-23 documents, Termination Reason: Unsatisfactory performance. Level of Harm - Actual harm V11's (Director of Human Resources) typed statement dated 1-4-23 and included in V3's employee record documents V3 did provide rough handling to the resident (R26) by improperly rolling her over, which caused significant bruising to (R26's) arm and concerns that V3 was forcefully providing cares to residents who were declining them, which is a violation of their resident rights. Residents Affected - Few On 03/21/23 at 9:45 AM R26 was lying in bed reading a book. R26 stated, A few months ago CNA/Certified Nursing Assistant (V3) jerked me by my arm and caused bruises. It hurt really bad. She was in a bad mood that day and was being rough. It hurt. I had turned her (V3) in for not giving me a bath and I think that was her (V3) way of getting back at me. I know the CNA was fired and no longer works here. On 03/21/23 at 01:00 PM V5 (LPN/Licensed Practical Nurse) stated, (R26) had reported to me that (V3) did not wash her up. I reported (V3's) concerns to (V8/Clinical Coordinator). A few days later I was helping (R26). (R26) was very upset and reported to me that (V3) had an attitude with her after (R26) had reported (V3) for not giving her a bath. (R26) told me that (V3) was rough with her and had grabbed her by the arm roughly and caused finger-print bruises to the left forearm. (R26) told me she felt very uncomfortable around (V3) and felt like (V3) was retaliating against her since (R26) had turned (V3) in for not giving her a bath. I had only worked with (V3) one day and the day I worked with (V3) she was very argumentative. 03/21/23 01:10 PM V8 (Clinical Coordinator) stated, (V5) had reported to me that (R26) said (V3) did not give her a bath. I spoke with (V3) and (V3) said she did give (R23) a bath and (R23) just probably forgot. I spoke with (R26), and she said (V3) did not give her a bath. (R26) is alert and orientated. On 03/21/23 at 1:15 PM V6 (CNA) stated, On (1-3-23) I was working day shift with (V3). That was the first day I had worked with (V3). (V3) was very argumentative with me that day and was upset because she did not get a break. (V3) was acting like she did not want to be here and was angry. I asked (V3) to wash up (R26). Around 10:00 AM or 10:30 AM (V3) was still complaining about not getting a break. I got fed up, so I told (V3) to just go take a break and we would handle the residents. I was tired of hearing (V3) complain. Me and V7 (CNA) went in to care for (R26) while (V3) was on break. When I entered (R26's) room, (R26) had tears and said that (V3) had grabbed her roughly by the arm. (R26) said she was in pain and had fingerprint fresh bruises to her left arm. (R26) said she did not want (V3) in her room anymore. I felt terrible that I had even asked (V3) to wash (R26) up. I immediately reported (R26's) bruises and allegations to (V4/Supervising RN). All I know is (V3) never did return from her break. 145436 Page 2 of 5 145436 03/23/2023 Apostolic Christian Restmor 1500 Parkside Avenue Morton, IL 61550

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to implement care plan goals and interventions for anticoagulant and antidiabetic medications for one resident (R41) of 26 (R41) in a sample of 26. Residents Affected - Few Findings include: The facility's Interdisciplinary Care Plan policy, revised 08/11, documents to assure the provision of care to meet the needs identified in the comprehensive assessment of every resident to achieve and maintain optimal resident status. R41's current Physician Order Report documents to inject insulin glargine (antidiabetic) 32 units subcutaneous every night, for type 2 diabetes mellitus. This form also documents to take Apixaban (anticoagulant) 5 milligrams twice daily, for a history of venous thrombosis and embolism. R41's current care plan does not documents goals and interventions concerning the use of an anticoagulant or antidiabetic agent. On 3/23/23 at 9:30am, V2, Director of Nursing, verified that R41's care plan does not document goals and interventions for the use of an anticoagulant or antidiabetic agent. V2 stated that both medications should be addressed on the care plan. 145436 Page 3 of 5 145436 03/23/2023 Apostolic Christian Restmor 1500 Parkside Avenue Morton, IL 61550

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received individualized treatment and services based on their comprehensive assessment to maintain, improve or prevent further decrease in range of motion for two of 13 residents (R49, R26) reviewed for range of motion in a sample of 26. Findings include: A Restorative Nursing: Positioning and ROM (range of motion) for Nursing Assistants course dated 2022 states, Range of Motion, or ROM, and proper positioning are important for the well-being of the people you care for. Immobility causes muscles and tendons to shrink, limiting mobility and making joint movement painful. If immobility continues, a contracture will eventually form. Proper range of motion techniques can help prevent these from developing. 1. R49's Minimum Data Set (MDS) assessment dated [DATE] documents R49 requires extensive assistance of two people for bed mobility, transfers and personal hygiene but requires extensive assistance of one person for dressing and toilet use. This same MDS documents R49 has a functional limitation in range of motion to both lower extremities and requires the use of a wheelchair for mobility. In addition, R49's MDS documents that R49 does not receive any passive or active range of motion program/services to maintain or improve R39's range of motion; or to address R49's functional limitation to both lower extremities. R49's list of current diagnoses includes Osteoarthritis. R49's Contracture Risk assessment dated [DATE], documented by V15 (MDS/Care Plan Coordinator), documents that R49 is very limited in her ability to perform activities of daily living (ADLs) and has minimal hypertonicity or weakness. This assessment documents that R49 has the present joint condition of moderately limited but does not indicate which joints are included in this assessment. This same assessment documents that R49 has Connective Tissue Disorders such as Osteoarthritis which contribute to R49's contracture risk. In addition, this assessment documents that no referrals for services are necessary and that R49's current care plan will continue. R49's care plan dated 8/15/22 documents that R49 is at risk or has contractures related to Alzheimer's disease and poor mobility. This same care plan documents the goal of this care plan is to increase or maintain R49's current function. The care plan intervention to address R49's contracture risk and functional limitation in range of motion includes, ROM's daily per physician's order. R49's physician's orders sheet (POS) dated 2/20/23 to 3/20/23 does not include any orders for R49 to have a range of motion program. On 3/20/23 at 10:48a.m. R49 was in her room seated in a wheelchair and was able to answer questions appropriately. R49 stated that she is unable to stand or walk and uses her wheelchair to propel herself around the facility. R49 also stated the facility is not providing a range of motion program to maintain or improve her joint mobility. On 3/20/23 at 11:09a.m. V16 (Certified Nurse Aide/CNA) stated that she is a regular CNA on R49's 145436 Page 4 of 5 145436 03/23/2023 Apostolic Christian Restmor 1500 Parkside Avenue Morton, IL 61550

F 0688 Level of Harm - Minimal harm or potential for actual harm hall. V16 stated that there is no specific ROM program or plan for providing ROM to specific joints for R49. When asked if she provides ROM to R49's hips because she is wheelchair bound, V16 stated that she usually just provides some general ROM to R49's arms and legs when she is dressing R49 in the morning. V16 stated she does not know what other CNAs do for R49 since there is no specific ROM program in place. Residents Affected - Few 2. R26's MDS (Minimum Data Set) Assessments dated 11-13-22 and 2-13-23 document R26 is cognitively intact, has functional limitations in range of motion to one side of the upper extremity and both sides of the lower extremities, and does not receive any restorative nursing programs to address R26's limitations in range of motion. R26's Contracture Risk assessment dated [DATE] documents R26 is at moderate risk of developing contractures. R26's Progress Notes dated 1-15-23 document R26 discussed with the rehabilitation aide request to discharge facility maintenance (restorative) program due to cost and R26's program would be discontinued. R26's Care Plan dated 3-1-23 documents R26 has impaired functional ability and mobility due to age, immobility, severe osteoarthritis, of multiple sites that impacts range of motion to bilateral lower extremities and bilateral upper extremities, weakness, arthralgias, history of falls, chronic pain, and a baker's cyst to the left knee. On 03/20/23 at 10:01 AM R26 stated, I have arthritis all over my body. I had an injury to my right shoulder and cannot lift my arms above my head. No one does exercises or therapy with me. R26 was lying in bed. R26's feet were contracted at the ankles and were facing outwards. R26 was unable to lift her arms above the chest level. On 03/20/23 at 10:05 AM V6 (Certified Nursing Assistant/CNA) stated, We (facility staff) do not do range of motion with (R26). I guess were probably should be. On 3/20/23 at 11:44a.m. and on 3/22/23 at 10:19a.m. V2 (Director of Nurses/DON) stated that residents are assessed for contractures using the Contracture Risk Assessment. V2 stated that if there are any problems found, the resident will be started on a range of motion program. V2 stated residents can also pay for a Functional Maintenance program which is priced at $10.00 per session. V2 stated, (R26) refused restorative programs because she did not want to pay the ten-dollar fee per session that the facility charges for restoratives. V2 also stated that R49's family declined to enroll R49 in the Functional Maintenance Program. On 3/21/23 at approximately 10:00a.m. V15 stated that CNAs provide some range of motion exercises to residents during cares. V15 stated there is no range of motion services provided based on individual resident's assessed needs, but instead, it is left up to the CNAs to determine how they will provide a resident with range of motion since they know the residents. V15 verified that R49 and R26's MDS assessment document that neither resident is receiving a ROM program. V15 stated that was because neither of these residents received a minimum of 15 minutes of ROM per day as is required by the MDS assessment in order to document that ROM was provided. 145436 Page 5 of 5