Inspection·October 6, 2022

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 provide services and/or treatments to increase range of motion/mobility and/or prevent further decrease in range of motion/mobility for three of seven residents (R8, R11, R43) reviewed for limited range of motion in the sample of 32. Findings include: The facility's Range of Motion and Physical Therapy policy dated 3/18/22, states Each resident will receive (Active/Passive) ROM (Range of Motion) twice a day and Physical Therapy will be provided as ordered by the physician and per written instruction of the P.T. (Physical Therapy) consult after evaluation. 1. On 10/03/22 at 10:59 a.m., R8 demonstrated her inability to completely extend all her fingers on her left hand without the assistance of her right hand. R8 stated she has diagnoses of Parkinson's Disease and Arthritis that are causing the range of motion to all her extremities to slowly deteriorate. R8 states she still ambulates independently with a walker but needs assistance with most of her cares. R8 stated at this time, she does not receive any type of services/treatments for her limitations of range of motion that exercises all her joints on a routine basis. R8's electronic medical record, documents R8 was admitted to the facility on [DATE] with diagnoses which included, Parkinson's Disease, Major Depressive Disorder, Obesity, Weakness, Repeated Falls, and Reduced Mobility. R8's Nurse Practitioners Progress Note dated 6/21/22, states R8 has a diagnosis of Primary Osteoarthritis involving multiple joints. R8's Minimum Data Set assessment dated [DATE], documents the following: R8 is cognitively intact with a Brief Interview for Mental Status score of 15 out of 15; R8 requires extensive assistance from staff with dressing, toilet use, personal hygiene and bathing; R8 has functional limitation in range of motion in her bilateral upper and lower extremities; and R8 is not receiving any type of range of motion program/services. R8's Contracture Profiles dated 3/2018 and 3/24/2020, document R8 had no loss of functional range of motion (Total Scores=0). R8's Contracture Profiles dated 7/29/20, 11/4/20, 4/14/21, 8/10/21, 10/6/21, and 1/5/22 document R8 has loss of active range of motion in her neck, bilateral shoulders, bilateral hips/knees, and bilateral feet (Total Scores=4). R8's Contracture Profiles dated 4/13/22, 7/13/22, and 10/3/22, document R8 has loss of active range of motion to her neck, bilateral shoulders, (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 4 Event ID: 145933 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 145933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Skylines 7023 North East Skyline Drive Peoria, IL 61614 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)