Health inspection·January 6, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 6. Findings include: R3's Facesheet dated 1/4/24 showed she had diagnoses to include, but not limited to: metabolic encephalopathy; lack of coordination; abnormalities of gait and mobility; repeated falls; spinal stenosis; unspecified adrenocorticoid insufficiency; congestive heart failure; chronic kidney disease (stage 3A), major depressive disorder; anxiety; and a history of falling. R3's facility assessment dated [DATE] showed she was cognitively intact. R3's Skilled Nursing Evaluation dated 12/15/24 showed she was alert and oriented to person, place, and time; communicated verbally; speech was clear; and was able to understand and be understood. R3's Care Plan initiated 10/21/24 showed, R3 is at risk of possible abuse/neglect related a history of abuse. The interventions included, but were not limited to: Provide me with physical/emotional safety by developing a trusting therapeutic relationship with me. On 1/4/24 at 12:51 PM, R3 was sitting up on the edge of her bed. R3 said she fell (12/18/24) when she tried to take herself to the bathroom. R3 said she wasn't sure exactly how she fell but remembered being on the floor and trying to scoot towards the bed to reach her call light. R3 said she couldn't stand herself up, nor could she reach the call light, so she yelled for help. R3 said V17 (CNA - Certified Nursing Assistant) responded. R3 said V17 came in and said, Oh my, I'm going to need some help to get you up. R3 said V17 left and returned with V18 (RN - Registered Nurse). R3 said as soon as V18 (RN) walked into the room he was questioning her, in a loud, accusing tone. R3 said V18 wouldn't let up and he said, It's my fault, I should have used the call light. R3 said V18 continued to stand over her and scold her like a child. R3 said she was still on the floor. R3 stated, It was so embarrassing, and [V17 -CNA] witnessed the entire thing. [V17] was even getting mad at [V18] and told him not to talk to me like that. R3 said she was on the floor 8-10 minutes with V18 (RN) standing over her and aggressively questioning her and stating, This shouldn't have happened. R3 said she finally snapped and said, Listen A******! I'm already on the floor. I didn't use the call light and fell and I couldn't get myself up. R3 said she told V18 that she wanted to get off the floor. R3 said that stopped the loud questioning, but she was in tears and upset because it went on for a while. R3 said V17 (CNA) and V18 (RN) were having a disagreement in front of her while V18 (RN) was assessing her. R3 said V17 and V18 assisted her into the wheelchair, then another nurse came in, but she didn't Page 1 of 3 145731 145731 01/06/2025 Citadel at Saint Benedict 6930 West Touhy Avenue Niles, IL 60714

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few know her name. R3 said she was very nice and had both V17 (CNA) and V18 (RN) leave the room and she helped her calm down. R3 said V1 (Administrator) talked to her on 12/19/24 and she told V1 what she told the surveyor. R3 said V1 told her that he was going to make sure that V18 (RN) didn't have any further contact with me. The facility's Final Reportable to IDPH dated 12/23/24 showed, R3 reported that V18 (RN) spoke inappropriately to her last night. R3 reported that V18 spoke to her in an aggressive manner when responding to her call for assistance after she fell when attempting to go to the bathroom on her own. This report showed V18 reported questioning why R3 tried to get up on her own. R3 became upset with the line of questioning and stated that he should not blame her for the fall. V19 (RN) said she went into R3's room to assist V18 and noticed R3 was upset. V19 asked V18 to leave the room and helped calm R3. This report showed, [R3] stated that [V19-RN] helped calm her down but felt that [V18] was questioning her in an aggressive tone regarding why she (was) attempting to toilet herself. On 1/4/24 at 2:17 PM, V18 (RN) said R3 had a fall on his shift (12/18/24). V18 said he has an accent and some people think that he talks loud. V18 said R3 was found on the floor by the CNA (V17). V18 said V17 alerted him and told him to call female nurse to assist me. V18 said he called V19 (RN) for assistance, then headed to R3's room. V18 said V17 was already in R3's room. V18 said he was surprised to see R3 on the floor like that and he may have seemed loud because he was surprised. V18 said he was just asking R3 questions to determine the cause of the fall. V18 said V17 (CNA) and V19 (RN) were in the room with him and R3. On 1/4/24 at 2:42 PM, V17 (CNA) said she was R3's assigned CNA on 12/18/24. V17 said she was in the hall charting and heard a noise. V17 said she stood to investigate the noise and heard someone yelling, Help! V17 said R3's door was closed, she opened it, and found R3 on the floor near her bed. V17 said R3 was in the seated position, on her butt, with her legs crossed in front of her. V17 said she told R3 that she needed to get help. V17 said she alerted V18 to R3's fall and told V18 to call a female nurse (V19) to help. V17 said R3 prefers females to provide hands on care. V17 said she returned to R3's room and V17 followed her. V17 said V18 stood over R3 and asked, How does it feel to be down there? Are you proud of yourself? V17 said she didn't like the way V18 was talking to R3 and stated, Why are you talking to her like that? V17 said V18 continued to loudly, aggressively question R3 while he stood over her (R3 was still on the floor). V17 said she told V18 (RN) to stop talking like that to R3 and he told her to Stay in her place. V17 said at that point R3 got really upset and yelled, I'm already down here Mother F***er, what do you want me to do? V17 said she told V18, She (R3) doesn't deserve that and again he told me to stay in my lane. V17 stated, I'm not going to watch him talk to a resident like that. That's abuse. He (V18) was standing over [R3] yelling. He was scolding her like a child. He just kept, repeatedly questioning her while she was on the floor. Then she snapped on him and he started to move. V17 said they assisted R3 up to the wheelchair before V19 arrived, but their disagreement continued. V17 said she was arguing with V18 (RN) and threatened to call the state. V17 said V19 (RN) arrived at that time and pulled me out of the room. V17 said V19 (RN) told her that she shouldn't be arguing with V18 (RN) in front of the residents and making threats to call the state. V17 said V19 (RN) wasn't there to hear how V18 spoke to R3. On 1/6/24 at 1:11 PM, V19 (RN) said she was working a different unit on 12/18/24 and V18 (RN) called her for assistance because R3 fell. V19 said when she got to R3's room, R3 was already up in the wheelchair but V17 (CNA) and V18 were arguing. V19 said she heard V17 threaten to call the state and she asked V17 (CNA) to leave the room. V19 said she told V17 that it's inappropriate to argue with another staff member in front of the resident and to make such comments. V19 said she went in to assist V18 (RN) and noticed R3 was upset and anxious. V19 said R3 prefers female staff to provide care 145731 Page 2 of 3 145731 01/06/2025 Citadel at Saint Benedict 6930 West Touhy Avenue Niles, IL 60714

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to her and she had assisted with her care before. V19 said she asked V18 (RN) to leave the room and tried to calm R3. V19 said R3 said it was her fault that she fell and that she just wants to go home. V19 said she didn't witness V18 aggressively questioning R3, but she wasn't able to come down to assist right away. V19 said R3 is alert and oriented and able to recall events. The surveyor asked V19 if a staff member should stand over a resident, on the floor, and ask, How does it feel to be down there? Are you proud of yourself? V19 replied, No, that should never be said to a resident. That's totally inappropriate. V19 said standing over someone, making those remarks, and aggressively questioning them could be considered verbal or mental abuse. V19 said she wasn't aware that V18 (RN) was scolding R3. On 1/6/24 at 1:27 PM, V2 (DON - Director of Nursing) said a resident shouldn't feel like they were being scolded like a child. The surveyor asked if V18 should stand over R3 and say, How does it feel to be down there? Are you proud of yourself? V2 replied, Absolutely not, that's inappropriate. Verbal abuse is the tone used and Mental Abuse is how you make the resident feel. V2 said if R3 felt embarrassed or humiliated, then it would be considered abuse. On 1/6/24 at 1:40 PM, V1 (Administrator) said on 12/19/24, V17 (CNA) reported that V18 (RN) yelled at R3 and spoke to her inappropriately. V1 stated, I'm not sure that she (V17) used the words verbal abuse. V1 said he interviewed R3. V1 said R3 reported that V18's tone was accusatory and she didn't appreciate his tone and questions. V1 said R3 didn't use the word scolded to him, but he could see how she would feel that way. The surveyor asked if V18 (RN) should have stood over resident and asked, How does it feel to be down there? Are you proud of yourself? V1 replied, No that could be abusive. V1 said that would be embarrassing. V1 said R3 never used the word abuse. The surveyor asked if the resident needs to identify it as abuse, for it to be abuse. V1 replied, No, that's probably my bad there. The facility's Abuse Prevention Program dated 10/2022 showed, Policy: This [facility] affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents . Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability . Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . 145731 Page 3 of 3