Health inspection·May 17, 2024

F 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 37 residents living at the facility. Residents Affected - Many Findings include: On 5/15/24 at 8:30am, V1 (Administrator) stated the current resident census is 37. V1 stated since the facility received a staffing citation from IDPH (The Illinois Department of Public Health) on 4/19/24, the facility signed a contract with a staffing agency. V1 stated the agency currently has nurses available which the facility is utilizing, but no CNAs (Certified Nursing Assistants) are available. On 5/15/24 at 9:15am, V3 (Power of Attorney/POA) of R1, stated on Tuesday 5/7/24 from about 3:30pm to about 6:00pm, the only CNA working was V11 (CNA). V3 stated during that time, she tried to find V11 for help transferring R1 into the wheelchair from the recliner and back again, but V11 was busy with other residents, and V3 stated she transferred R1 by herself although it takes two people to transfer R1. V3 stated the facility has an ongoing problem with being short staffed. V3 stated because of this, she has decided to have R1 discharged to home with in home care at the end of May 2024. On 5/15/24 at 10:45am, R4 was alert and oriented. R4 stated there are ongoing issues with staffing. R4 stated call lights can take up to an hour to be answered especially on overnight shift (10pm-6am), and there have been times in past month where only one CNA and one nurse were the only two staff in the building on overnight shift. R4 stated V7 (Registered Nurse [RN]/Minimum Data Set[MDS]/Care Plan Coordinator[CPC]) works as a floor nurse and sometimes as a CNA almost every weekend, in addition to her Monday through Friday job duties. On 5/15/24 at 11:00am, R2 was alert and oriented. R2 stated call lights take up to an hour especially on evening shift (2:00pm to 10:00pm) and overnight shift on weekends. R2 stated in the past month there have been times on the overnight shift when there is only one nurse and one CNA for the whole building, and she has noticed some of the CNAs working doubles due to the oncoming shift not relieving them. On 5/15/24 at 11:20am, R3 was alert and oriented. R3 stated she doesn't use the call light so she can't say how long it might take to get answered. R3 stated sometimes on night shift there are only two staff in the building, one CNA and one nurse, and sometimes the CNAs are working doubles because nobody is coming in to relieve them. On 5/15/24 at 2:20pm, V9 (CNA) stated in the past month, she has at times been the only CNA in the Page 1 of 3 145807 145807 05/17/2024 Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many building, usually not for a whole shift but for a partial shift. V9 stated it is very difficult to meet all resident care needs under these circumstances. On 5/15/24 at 2:40pm, V11 (CNA) stated she has worked at the facility for about 3 weeks. V11 stated on 5/7/24 from 2:00pm to about 5:30pm, she worked alone with V5 (Registered Nurse/RN) because the 2pm to 10pm CNA called in sick. V11 stated it was very difficult to get residents fed, keep them clean and dry, and transfer them with only the help of V5. V11 stated on 5/3/24, she worked from 6:00am to 6:00pm because the evening shift CNA did not show up at 2:00pm. On 5/15/24 at 3:00pm, V5 (RN) confirmed in the past month, CNAs are occasionally working alone for part of a shift until coverage can be found. On 5/16/24 at 8:40am, V13 (Licensed Practical Nurse/LPN) stated within the past month, there have been overnight shifts with her and one CNA providing care for the whole building. On 5/16/24 at 8:50am, V14 (RN/Agency Nurse) stated she has only worked at the facility for a few weeks. V14 stated she works the 6:00am to 6:00pm shift. V14 stated there have been occasions on the weekends when she and one CNA were the only staff in the building. On 5/16/24 at 9:55am, V7 (RN/MDS/CPC) stated in the past month, there have been instances of one nurse and one CNA taking care of the whole building, Maybe not for a whole shift, but part of a shift. V7 confirmed she has also worked shifts as a CNA during that period because coverage could not be found, as well as working her 40 hour a week position as Minimum Data Set/Care Plan Coordinator and recently added duties of Interim Director of Nursing. On 5/16/24 at 12:55pm, V1 (Administrator) stated she is the staff member responsible for scheduling. V1 stated if residents were truly concerned about staffing they would be filing grievances, and they haven't. V1 stated she believes the facility is meeting minimum staffing requirements. V1 stated she,Tries to schedule 2 CNAs every 8 hour shift and one nurse every 12 hour shift. V1 stated CNAs working alone with one nurse on night shift is not uncommon. V1 stated, If staff call in, we do our best to get coverage. If I can't get coverage there is nothing I can do.We can't mandate staff to work. There is nothing I can do if the staffing agency doesn't have any CNAs. V1 stated she has just hired three new CNAs. On 5/16/24 at 1:25pm, V2 (Corporate Regional Director of Operations) stated she does not believe there is a problem with staffing at the facility, she Believes there is a problem with the staff and the residents' perception that they need to have more staff. V2 stated the staffing agency with which they have contracted, Have CNAs available but none are willing to come to the facility. On 5/17/24 at 7:50am, V4 (Ombudsman) stated in the past month, residents have complained about, Call lights taking too long, and the facility being short staffed, both of which are ongoing problems. V4 stated she intends to increase monitoring at the facility in relation to these issues. Nursing and CNA Schedules for April and May 2024 documented the following dates with one CNA and one nurse providing care for the entire facility: 5/1/24: 2:00pm to 10:00pm 5/3/24: 2:00pm to 10:00pm and 10:00pm to 6:00am 145807 Page 2 of 3 145807 05/17/2024 Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448

F 0725 5/7/24: 2:00pm to 6:00pm Level of Harm - Minimal harm or potential for actual harm 5/13/24: 2:00pm to 5:00pm and 10:00pm to 6:00am A Room Roster dated 5/15/24 documented a total of 37 residents living at the facility. Residents Affected - Many 145807 Page 3 of 3