Health 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 Page 1 of 3 145673 145673 10/14/2022 Apostolic Christian Home of Eureka 610 Cruger Eureka, IL 61530

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few as well as state/federal guidelines and regulations. Including a minimum of the following: .i. Promptly respond to resident's call lights. 1. On 10-11-22 at 10:11 am, R39 stated that R39 has to wait a long time for staff to come when R39 puts the call light on. R39 stated I have waited an hour before. R39 stated R39 has had urinary accidents while waiting and I go through a lot of diapers. I'm getting used to it. It's been this way since I've been here. R39's current Care Plan documents R39 admitted to the facility on [DATE]. R39's admission Minimum Data Set/MDS assessment, dated 8-8-22, documents R39 is cognitively intact, requires extensive assistance with transfers and toileting, is frequently incontinent of bladder, and consistently continent of bowel. On 10-12-22 at 12:34 pm, V9 (R39's family member) sat in R39's room and stated the following: Yesterday V9 was with (R39) when (R39) put the call light on to use the bathroom (for a bowel movement) at 25 minutes past the hour. V9 could not recall what time of day it was, but it was 10 minutes past the next hour (total of 45 minutes) before someone came. (R39) held it for that long but was passing gas. (R39) grumbled about it. 145673 Page 2 of 3 145673 10/14/2022 Apostolic Christian Home of Eureka 610 Cruger Eureka, IL 61530

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to change gloves during toileting for two of three residents (R39 and R60) reviewed for incontinence care in a sample of 34. Residents Affected - Few Findings include: The facility's policy Toileting Assistance, dated 5-2010, documents Procedure: TOILETING: Wash your hands and gather equipment .Put on disposable gloves if needed and additional PPE if indicated .Assist resident onto toilet or with appropriate receptacle .Once elimination has been completed, perform peri care .Remove your soiled gloves and wash your hands. Apply new clean gloves .Position resident comfortable with call light within reach .Throw gloves in soiled/urinated attends in the garbage bag provided in each resident's bathroom and dispose of immediately in the dirty utility room. Perform hand hygiene. The Facility's policy Infection Control Handwashing, undated, documents PURPOSE: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections .NOTES: Always follow Standard Precautions. Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, non-intact skin, etc., is anticipated. Change gloves and discard after each resident contact. One (1) pair of gloves - one (1) resident. Change gloves when moving from a contaminated body site to a clean body site on the same resident. 1. On 10-11-22 at 9:52 am, V8 Certified Nursing Assistant/CNA assisted R39 with toileting. After R39 voided V8 wiped R39's front and back areas. With the same soiled gloves V8 pulled up a clean incontinence brief, R39's pants up and adjusted R39's shirt. V8 removed V8's gloves then without hand sanitizing V8 assisted R39 to a recliner then left the room for a straw. V8 retrieved a straw just down the hall, brought it back to the room opened it and placed it in R39's drink. V8 tied up the bathroom garbage and then hand sanitized and left the room. On 10-13-22 at 1:30 pm, V8 CNA stated that V8 should have changed V8's soiled gloves after cleaning R39 up. 2. On 10-12-22 at 9:25 am, V8 Certified Nursing Assistant/CNA and V4 Infection Control Preventionist/ICP assisted R60 to stand with the lift and transported R60 to the bathroom. With gloved hands V8 CNA removed R60's soiled brief then lowered R60 to the toilet. After R60 voided and with the same soiled gloves V8 CNA wiped R60's perineal area front to back. With the same soiled gloves V8 CNA put a clean incontinence brief on and handled the lift to transfer R60 back to bed. As V8 CNA assisted R60 into the bed, V8 touched R60's clothing and skin, pulled the linens up and adjusted the head of the bed with the bed control. V8 then used hand sanitizer on V8's gloves and assisted R60 to eat/drink a little. On 10-12-22 at 9:45 am, V8 CNA stated I should have changed my gloves after removing her brief and again after wiping her. There weren't any in the bathroom. Then I used hand sanitizer on my gloves thinking that may help. 145673 Page 3 of 3