Inspection·October 14, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Quarterly MDS (Minimum Data Set) assessment for R1, dated 9/23/22, documents R1 is cognitively intact and requires extensive assistance with transfers, toileting, and is occasionally incontinent of bladder and frequently incontinent of bowel. Residents Affected - Few The Current Care Plan for R1 documents Provide prompt assistance to the toilet upon request to promote my continence. On 10/11/22 at 10:29 AM, R1 stated It takes them way too long to answer the call lights. I wait at least 20 minutes on a consistent basis. On 10/12/22 at 12:44 PM, upon entering hallway, noted R1's call light sounding and lit up over R1's door. On 10/12/22 at 12:54 PM, R1 propelled his wheel chair out into the hallway and waited for a staff member to come by. At this same time R1 alerted a staff member that was walking past him that he needed assist to the bathroom. Unable to determine when the call light was initiated however, total observed wait time was ten minutes. R1 stated he had been waiting for over 30 minutes for someone to come and no one came until he went and sat in the hallway. On 10/14/22 at 9:34 AM, V2 DON (Director of Nursing) stated the facility does not have a specific policy and procedure for resident call lights. On 10/14/22 at 1:50 PM, V2 stated, Obviously we want them (the staff) to answer call lights immediately if they can, if possible; but realistically, goals would be five to ten minutes. Based on interview and record review, the facility failed to ensure resident call lights were responded to in a timely manner for 2 of 18 residents (R1 and R39) reviewed for call lights in a sample of 34. Findings include: The facility's Job Description for Certified Nursing Assistant (CNA), revised 10-1-07, documents Scope of Position: The purpose of the Certified Nursing Assistant (CNA) position is to provide each of the assigned residents with routine daily nursing care and services in accordance with the resident's care plan and with the policies and procedures of this facility under the direction of the (a.)Lead CNA (b.)Unit Coordinator (c.)Charge Nurse (R.N./L.P.N.) (d.)Assistant Director of Nursing (e.)Director of Nursing or (f.)Administrator, to assure that the highest degree of quality of resident care is provided at all times .Job Responsibilities: 1. Provide personal care to residents in a manner conducive to their safety and comfort consistent with the facility clinical policies and procedures (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 3 Event ID: 145673 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 145673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home of Eureka 610 Cruger Eureka, IL 61530 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)