Health inspection·October 4, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assist dependent residents with repositioning and incontinence care for 2 of 3 residents (R5 and R 15) reviewed for Activities of Daily Living (ADL's) in a sample of 18. Residents Affected - Few The findings include: 1. R5's New admission Information sheet in the medical record documents and admission date of 2/24/2017. R5's Physician Order Sheet dated 9/1/2024, documents diagnoses including Physical Debilitation, Hypertension, Anxiety, Osteoarthritis, Psychosis, and Moderate to Severe Dementia. R5's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 2, indicating R5 has severe cognitive impairment. Section GG, Functional Abilities and Goals, documents R5 is totally dependent on staff for all functional abilities. Section H, Bladder and Bowel, documents R5 is always incontinent of bowel and bladder. R5's Care Plan documents a Focus area of the risk for alteration in skin integrity related to decreased mobility. Documents interventions, with revision date of 8/27/2024, include peri care and barrier cream as needed after incontinent episodes. The same Care Plan also documents a Focus area dated 5/16/2024 of R5 requiring staff assist with ADL's (Activity of Daily Living). Intervention dated 8/27/2024, assist with bed mobility. Focus dated 8/28/2024, documents R5 is incontinent of Bowel and Bladder. Documented interventions, dated 8/28/2024, include change every 2 hours and as needed per staff and clean peri area with each incontinence episode. On 9/26/2024 at 12:15 PM, upon entering the facility, R5 was observed sitting in the day area in a geriatric recliner, positioned on left hip with a pillow observed behind the right hip. From 12:30PM through 3:18PM R5 was observed to be remaining in the same position in the geriatric recliner, on the left hip with a pillow placed under the right hip. R5 remained in the same location in the day room area. On 9/26/2024 at 3:20PM, V2 (Licensed Practical Nurse/ Minimum Data Set Director) stated that R5 should be repositioned and have peri/incontinence care every 2 hours. V2 stated R5 had been in day room area since lunch. On 9/26/2024 at 3:30PM, V5 (Certified Nursing Assistant/CNA) was asked how often R5 should be checked and repositioned and V5 stated every 2 hours at least. V5 stated she works 2PM -10PM and she Page 1 of 3 145759 145759 10/04/2024 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assumes R5 was checked and repositioned around 1:00PM. V5 stated R5 is always incontinent of bowel and bladder and is dependent on the staff for incontinence care and repositioning. V5 stated R5's skin always looks red. On 9/26/2024 at 3:30PM, V5 and V6 (CNAs) took R5 to her room per the geriatric recliner and transferred R5 to the bed with the mechanical lift. R5 was provided incontinence care with noted redness to peri area and thighs. A new disposable undergarment was placed on R5 and R5 was transferred back to the geriatric recliner with the mechanical lift. 2. R15's New admission Information sheet in the medical record documents an admission date of 6/7/2023. R15's Physicians Order Sheet dated 9/1/2024 documents diagnoses including Left Middle Cerebral Cardiovascular Accident, Right Sided Hemiparesis, Aphasia, Hypertension, and Depression. R15's MDS dated [DATE] documents a BIMS score of 1, indicating R15 has severe cognitive impairment. Section GG, Functional Abilities and Goals, documents R15 requires substantial/maximal assistance for toileting and dressing and R15 requires partial/moderate assist for turning and repositioning and showers. Section H, Bladder and Bowel, documents R15 is always incontinent of bowel and bladder and is not on a toileting program. R15's Restorative Nursing Program Documentation documents that R15 is involved in a dressing program, transfer program, bed mobility program, and passive range of motion program. R15's Care Plan documents a Focus area, with a revision date 8/29/2024, of Bowel and Bladder incontinence. Documented interventions for this focus area, dated 8/29/2024, include check resident every 2 hours and assist with toileting as needed and provide peri care after each incontinence episode. R15's Care plan also documents a Focus area, with a revision date of 6/11/24, of alteration in skin integrity related to decreased mobility with documented interventions including staff assistance with peri care and toileting. On 9/26/2024 at 12:15 PM, upon entering the facility, R15 was observed sitting in the day area in a standard wheelchair. From 12:30PM through 3:18PM, R15 was observed to remained in the wheelchair with periods of leaning over and sleeping. Throughout this time, R15 remained in the same location in the day room area. On 9/26/2024 at 3:20PM, V2 (Licensed Practical Nurse /Minimum Data Set Director) stated R15 should be repositioned and have peri/incontinence care every 2 hours. V2 stated R15 had been in Day Room since lunch. On 9/26/2024 at 3:50PM, V5 (CNA) was asked how often R15 should be checked and repositioned. V5 stated every 2 hours at least. V5 stated she came in to work at 2 PM and she assumes R15 was checked and repositioned by the day shift on the 1:00PM rounds. V5 stated R15 is always incontinent of bowel and bladder and dependent on the staff for transfers and incontinence care. On 9/26/2024 at 3:50PM, R15 was taken to her room via wheelchair by V5. V5 transferred R15 using a gait belt. V5 provided incontinence care with urine noted to disposable undergarment. A new disposable undergarment was placed on R15 and R15 was left in bed to rest. 145759 Page 2 of 3 145759 10/04/2024 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0677 Level of Harm - Minimal harm or potential for actual harm The facility policy titled Preventative Skin Care, dated 1/18, documents It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. Residents Affected - Few 145759 Page 3 of 3