Health inspection·August 24, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide incontinence care to residents' dependent on staff for care for 5 of 5 residents (R1-R5) reviewed for incontinence care in the sample of 5. Residents Affected - Few This failure resulted in psychosocial harm as evidenced by R2 being upset and angry for lying in a soiled incontinence brief for over four hours and stating it makes her pissed and disgusted, R1sitting in a soiled incontinent brief for over six hours and stating he felt like a second class citizen, and R4 stated in the morning she is soaked through to the bed linens and can't feel like a person when this happens. The findings include: 1. R4's face sheet showed an [AGE] year-old female with diagnosis of rheumatoid arthritis, chronic kidney disease Stage 3, hypertension, heart failure, urinary tract infection, and falls. On 8/24/23 at 10:50 AM, R4 said she urinates a lot and uses incontinence briefs. They put a pad inside my brief too to help. Nobody usually comes in during the night to check and change me. This morning, I was soaked through to the bed linens. I can't move to assist them. It makes me worry about the residents that can't speak for themselves. It's terrible. I can't feel like I'm a person. I have a sore on my bottom that I didn't have before I got here. At 12:22 PM, V4 Director of Nursing said residents should be checked and changed every two hours whether they are alert or not. Some residents want to be independent so may not request assistance. If incontinent care is needed and not given you could have skin issues, infection, and their dignity can be affected. To provide appropriate care for the residents, the staff need supplies and access to supplies. Central supply has a key to the supply area, the receptionist and shift supervisors do as well. At 2:12 PM, V2 facility Medical Director said incontinent residents should be checked and changed every couple hours. That would be appropriate and his expectation. Complications that may occur if incontinence care is not done include UTI (urinary tract infection), sepsis, skin infections, bed sores and worsening of bed sores. Staff should always have access to the needed supplies to provide care to the residents. R4's 7/7/23 facility assessment showed she was cognitively intact, required extensive assistance of one plus persons to physically assist with transfers and toileting. This assessment showed R4 was frequently incontinent of bladder and bowel. Page 1 of 4 145511 145511 08/24/2023 Bella Terra Lombard 2100 South Finley Road Lombard, IL 60148

F 0677 Level of Harm - Actual harm Residents Affected - Few R4's care plan showed she was at risk for skin breakdown and to keep her skin clean and dry. R4's ADL care plan showed a self-care deficit and impaired mobility related to a UTI (urinary tract infection), gout, and myeloplastic syndrome. This care plan showed R4 required extensive staff participation to toileting. R4's incontinence care plan showed for staff to check on her every two hours and that she requires assistance to wash, rinse, and dry her perineum. R4's physician order sheet showed a 6/4/23 approval of the care plan. The facility's 7/28/23 Incontinent and Perineal Care Policy showed it is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Do rounds at least every two hours to check for incontinence during shift. The facility's 7/28/23 General Care Policy showed it is the facility's policy to provide care for every resident to meet their needs. The facility will evaluate the need for physical and psychosocial needs. Physical needs would include ADL, wound care, medical needs, etc. Psychosocial needs would include but are not limited to areas of mental and psychosocial well-being. The facility will assist the resident to meet these needs. 2. R1's face sheet showed a [AGE] year-old male with diagnosis of right sided hemiplegia and hemiparesis following a cerebral infarction, dementia, heart failure, urinary tract infection, major depressive disorder, anxiety disorder, bilateral deep vein embolism and thrombosis, morbid obesity, hypertension, and acute respiratory failure. On 8/24/23 at 9:45 AM, R1 was lying in bed on his back. R1 said he was currently sitting in a soiled incontinent brief. R1 said he was last changed around 4:00 AM. R1 said the staff were aware but did not have the supplies available to change him. R1 said if they can't get to me, how many others aren't getting care? It happens a lot. It makes me feel like a second-class citizen. At 10:25 AM, V8 Certified Nursing Assistant (CNA) said she's waiting on the big diapers. V8 said there are four resident who use bariatric diapers and identified R1, R2, and R3 as those that do. V8 said R4 wears a 2XL incontinent brief and had been given incontinence care her shift (6 AM-2 PM). V8 said R1-R3 had not been given incontinence care this shift because there were no bariatric incontinent briefs available to use. V8 said this has been going on for weeks and management gets mad when we ask for supplies and reprimand us if we talk to you. Another CNA made a list of each resident's incontinent supply needs (on the second floor) and gave it to V1 Administrator about a week ago. At 10:45 AM, V8 entered R1's room to provide incontinence care. R1's 7/14/23 facility assessment showed he could make himself understood and was able to understand others, required extensive assistance of two plus persons to physically assist for bed mobility and toilet use. This assessment showed R1 had upper and lower extremity impairment on one side and was always incontinent of bladder and bowel. R1's care plan showed he was at risk for skin breakdown related to impaired mobility and incontinence. Keep skin clean and dry. R1's 6/7/22 care plan showed antibiotic use related to recurrent UTI (urinary tract infection). R1's ADL (activity of daily living care plan) showed he requires extensive assistance of two staff for peri care. R1's incontinence care plan showed staff to check every two hours for incontinence and aid wash, rinse, and dry his perineum. 145511 Page 2 of 4 145511 08/24/2023 Bella Terra Lombard 2100 South Finley Road Lombard, IL 60148

F 0677 R1's physician order sheet showed a 7/12/23 order for certification and approval of the care plan. Level of Harm - Actual harm 3. R2's face sheet showed a [AGE] year-old female with diagnosis of morbid obesity, chronic kidney disease Stage 4, chronic obstructive pulmonary disease, heart failure, type 2 diabetes, and major depressive disorder. Residents Affected - Few On 8/24/23 at 10:07 AM, R2 was lying in bed with a sheet and incontinent brief on. R2 said she was incontinent and asked to be changed at 7:00 AM. It's absolutely friggin ridiculous. It makes me extremely pissed and disgusted. R2 said the CNAs don't have access to the supplies so it's not their fault. I wouldn't treat my dog like this. This happens almost daily. R2 said she called V3 Assistant Administrator several times to complain. V3 didn't respond until I told her I was going to call the state. After that, diapers appeared and now it's starting over again. At 10:30 AM, V8 accompanied this surveyor to the clean utility room. There were no bariatric incontinent briefs on the shelf and one open package of 2XL briefs. V9 Central Supply was in the clean utility room stocking incontinent supplies. V9 said bariatric briefs are locked in the medication room and staff must ask the nurse for those supplies. V9 accompanied this surveyor into the medication room and there were no bariatric incontinent briefs available. At 10:46 AM, V9 said supplies used to be kept in resident rooms but it was a fire hazard to store the briefs on the top shelf near the sprinklers. Staff were using the bariatric briefs on the wrong residents, so none were available when a bariatric resident needed them. So now, the nurses restricted them. Staff must ask the nurse for the bariatric briefs. At 11:17 AM (four hours after R2 asked to be changed), V8 CNA removed R2's two incontinence briefs. There was a 2XL and a bariatric brief on R2. Urine had soaked through the 2XL brief (closest to R2's skin) and the bariatric brief. R2's skin was intact to her buttocks. R2 and V8 said R2 needs to be changed at least four times a shift. At 11:37 AM, incontinence care and supplies concerns were discussed with V1 Administrator. V1 said staff were not using briefs inappropriately so the 3XL (bariatric) briefs were locked in the med room. At 12:37 PM, V14 Registered Nurse (RN) said V8 asked her for some 3XL incontinent briefs this morning and there were none available. V14 said she didn't notify anyone that they needed supplies because there's no one to call until V9 gets here after 8:00 AM. V14 said even after 8:00 AM, she did not call anyone. R2's 6/15/23 facility assessment showed she was cognitively intact, required extensive assistance of two plus persons to physically assist with bed mobility and toilet use. This assessment showed R2 was always incontinent of bowel and frequently incontinent of bladder. R2's care plan showed she was at risk for skin breakdown related to incontinence and to keep skin clean and dry. R2's ADL care plan showed she required two staff to assist with peri care. R2's incontinence care plan showed for staff to check her for incontinence every two hours, and she required assistance to wash, rinse, and dry her perineum. 4. R3's face sheet showed a [AGE] year-old female with diagnosis of morbid obesity, 145511 Page 3 of 4 145511 08/24/2023 Bella Terra Lombard 2100 South Finley Road Lombard, IL 60148

F 0677 polyosteoarthritis, Asperger's syndrome, and hypertension. Level of Harm - Actual harm On 8/24/23 at 10:20 AM, R3 was laying in her bed uncovered with a hospital gown and incontinent brief on. R3 said she was currently laying in a wet brief. R3 said she's used to it as she's had incontinence and a lot of leakage for about 20 years. R3 said sometimes she calls to be changed and sometimes she doesn't. R3 said she hasn't complained although she sometimes waits over an hour for someone to change her. Residents Affected - Few R3's 7/8/23 facility assessment showed she was cognitively intact, required extensive assistance of two plus persons to physically assist to toilet and transfer. This assessment showed R3 was always incontinent of bowel and bladder. R3's care plan showed she was at risk for skin breakdown related to muscular disorders, obesity, osteoarthritis, and abnormal gait and mobility. Keep skin clean and dry. R3's ADL care plan showed she required 2 staff to participate in toileting and transfer. R3's incontinent care plan showed for staff to check her for incontinence every two hours and needing assistance to wash, rinse, and dry, her perineum. 5. R5's face sheet showed a [AGE] year-old female with diagnosis of multiple sclerosis, depressive disorder, hypertension, type 2 diabetes, moderate protein-calorie malnutrition, and obsessive-compulsive disorder. On 8/24/23 at 11:15 AM, R5 was laying supine in bed. R5 said she wears incontinent briefs and is not checked or changed during the night unless she puts her light on. I'm always wet in the morning. Sometimes I wear two diapers and soak through both by morning. They don't have supplies. Sometimes they're out of diapers, pads and wipes. The staff look just not happy when they don't have the supplies to care for you. It's not the CNAs fault. R5's 8/15/23 facility assessment showed she was cognitively intact, dependent on staff for toilet use, and required extensive assistance for bed mobility and transfer. This assessment showed R5 was frequently incontinent of bladder and bowel. R5's care plan showed she was at risk for skin breakdown related to immobility and incontinences. Keep skin clean and dry. R5's care plan showed impaired mobility related to multiple sclerosis. R5's ADL care plan showed she required total staff participation to use the toilet and two staff to transfer. R5's incontinence care plan showed for staff to check for incontinence every two hours, and she required assistance to wash, rinse, and dry her perineum. 145511 Page 4 of 4