Health inspection·November 6, 2024

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate staffing for Certified Nursing Assistants in two units within the facility. This failure applied to three of three (R1, R2, R3) residents reviewed for staffing and has the potential to affect 29 residents currently residing in the two units (Suites North and Suites South). Findings include: Per Facility Census dated 11/4/2024 shows there are currently 29 residents residing in two units, [NAME] Suites North and Suites South-total Census of 152 residents residing in the facility. On 11/4/2024, during the course of this survey, R1, R2, and R3 all resided in the Suites North unit. Facility Assessment Tool 2024 with last review date of 7/10/2024 states in part but not limited to the following: The tool is used to inform staffing decisions to ensure that there is enough staff with appropriate competencies and skill sets necessary to care for its residents needs. Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of residents at any given time. Direct care staff: CNAs (Certified Nursing Assistants): 1 CNA per 11 Residents for the day shift, 1 CNA per 11 Residents for the evening shift, and 1 CNA for 13 residents for the night shift. The Daily Schedule dated 10/6/2024-11/3/2024 shows that one CNA worked on Suites South and one CNA worked on Suites North for all shifts, including the day shift, evening shift, and night shift. It is to be noted that on 11/4/2024, Suites North had 14 residents, and Suites South had 15 residents. On 11/4/2024 at 10:05 AM, R1 was interviewed regarding care within the facility. R1 said she feels that the CNAs have too much to do and that they are assigned too many residents for one CNA to take care of. She says sometimes she has to wait for her call light to be answered for an extensive period of time. R1 says the facility staff has never given her a shower, but the hospice staff is the only staff member who has ever provided her with a bed bath. Hospice provides this to residents, however, only once a week. At 10:45 AM, R2 was observed to be lying in bed in a gown sleeping. It is to be noted that R2 had facial hair on the upper lip and chin. Page 1 of 2 145198 145198 11/06/2024 Bella Terra Morton Grove 8425 Waukegan Road Morton Grove, IL 60053

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some At 10:55AM, R3 was observed in her room lying in bed in a gown with V9 (a Family Member) at her bedside. V9 said there is not enough staffing of CNAs on this unit, and there seems to be a shortage. She says there are times when she will come visit her, and she is not yet dressed or ready for the day. At 11:15 AM, V5 (Licensed Practical Nurse) was interviewed regarding staffing on the North Suite unit. V5 said I am the regular nurse assigned to this unit. Says we do use a lot of agency staffing over here and the current CNA that is working is an agency CNA. V5 said having agency CNAs on this unit can be difficult because they do not know the resident and their needs. V5 also said that R2 requires a mechanical lift and requires two-person assistance with transferring. Says this slows me down on medication pass because I am the one that is required to help assist the CNA. At 12:35PM, V5 said that when both units, Suites North and Suites South, are full, we are supposed to have another CNA who splits rooms from both units. However, we are currently full and only have one CNA working. V5 said I had a discharge today and am getting a new admission already. V5 also said that I had worked in this unit for two years and had never had more than one CNA work on it. At 3:05 PM, V11 (Registered Nurse) was interviewed regarding the staffing of Suites South. V11 said there is only one CNA assigned to the South unit today, which is typical staffing. V11 said it can get difficult when all the beds are full and we only have one CNA working. When there is an agency CNA assigned, it can be extra difficult to provide adequate care to the residents. V11 said we have two residents on this unit who require two-person assistance, which means I am expected to help assist the CNAs with this, as well as residents who need assistance with feeding at meals. At 1:45 PM, V3 (Nursing Scheduler/CAN Supervisor) was interviewed regarding the staffing needs of CNAs. V3 said, I was told by administration that I am to staff one CNA on Suites North and one CNA on Suites South for each of the three shifts. However, everything is based on the Census, so when that section is full, and we have over 150 residents, we staff another CAN on this unit to split residents between Suites North and Suites South. A review of the Payroll-Based Journal Staffing Data Report for FY Quarter 3 2024 (April 1 - June 30) indicates that the facility was triggered for an area of concern related to the One Star Staffing Rating. 145198 Page 2 of 2