Health inspection·June 1, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's call light was answered in a timely manner to meet the resident's need for one of four residents (R3) reviewed for accommodation of needs in the sample of four. Findings include: The facility's Call Lights Policy, dated 8/14/21, states, Purpose: 1. To respond promptly to resident's call for assistance. Procedure: 1. All facility personnel must be aware of call lights at all times. 2. Answer all call lights promptly whether or not the staff person is to the resident. 3. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as possible. The Residents' Rights for People in Long Term Care Facilities, dated 11/18, documents the facility must provide residents services to keep their physical and mental health at their highest practical level and the facility must provide care that promotes residents' quality of life. The facility's Certified Nursing Assistant/CNA Job Description, undated, states, Essential Duties and Responsibilities: Answers residents' call lights promptly and courteously. The facility's Resident Council Minutes for May 2023 states, We need more CNAs/Certified Nursing Assistants on the floor. R3's Facesheet documents R3 admitted to the facility on [DATE] with diagnoses to include but not limited to: Nondisplaced Traverse Fracture of Right Patella; Morbid Obesity; Nondisplaced Fracture of Greater Trochanter of Right Femur; Generalized Muscle Weakness; Difficulty Walking; Unsteadiness on Feet; and a Previous Fall. R3's Minimum Data Set/MDS Assessment, dated 5/23/23, documents the following: R3 is cognitively intact with no memory impairments, scoring a 15 out of 15 on the Brief Interview of Mental Status (BIMS); R3 is always continent of urine and bowel; R3 requires extensive assistance of two plus persons physical assist for transfers, bed mobility, walking in room, and toilet use; R3 is not steady, only able to stabilize with staff assistance for moving on and off the toilet; R3 has range of motion impairment on one side of R3's lower extremities; and prior to R3's current illness, R3 was independent for R3's self care needs, including toilet use. R3's Current Care Plan at the time of R3's admission documents the following: (R3) has a deficit in ADL/Activities of Daily Living abilities and requires staff assistance due to fall in the community Page 1 of 3 145426 145426 06/01/2023 Pavilion of Ottawa 704 East Glover Street Ottawa, IL 61350

F 0550 Level of Harm - Minimal harm or potential for actual harm with fracture of right patella. WBAT (Weight Bearing as Tolerated) to RLE (Right Lower Extremity) with immobilizer in place at all times. (R3) is alert oriented and able to make needs known. with an intervention of Assist with all transfers and maintain any weight bearing restrictions.; (R3) is at risk of falls due to history of fall in the community with fracture. (R3) has impaired mobility and weakness and requires assistance with transfers. (R3) takes medications that increase her risk of Residents Affected - Few falls. with an intervention of Call light in reach and answer in a timely fashion.; and Assist me with my personal cares as needed. On 5/31/23 at 10:26 AM, V13 (R3's Family Member) stated, On 5/23/23 shortly after 8:00 AM, I came to visit (R3). (R3's) call light was on when I got there. I asked (R3) how long her light has been on and she said at least a half hour. (R3) said she had to go to the bathroom badly. I took (R3) to the bathroom myself. The nurse came in the room when we were finishing and told me to not transfer (R3) on my own. I talked to (V2/Director of Nursing) right after that happened because I shouldn't have to be the one who helps (R3) to the bathroom. A couple days later, (5/25/23) (R3) called me very upset that she had to go to the bathroom so bad and had been waiting over an hour for help. (R3) ended up soiling herself because no one ever came. (R3) knows when she has to go to the bathroom. That shouldn't have happened. I came to the facility and went to the Administrator (V1). I let her know I wanted to take (R3) home that day with me since no one seemed to be taking care of her there (at the facility). On 5/31/23 at 3:19 PM, R3 stated, I wasn't at the facility for a very long time. I didn't need very much, just help to go to the bathroom. One day (5/23/23), (V13) had to help me to the bathroom because no one was coming in. I had already been waiting a half hour. The day I came home (5/25/23) was even worse. I waited over an hour. I remember I saw a male nurse in the hallway. I was thinking, 'Why is no one coming in? Why does it take that long?' I had to pee so bad that it hurt. They were giving me laxatives and I didn't know it. I kept pushing my button over and over. I don't know if that does anything, but I really needed help, so I just kept pushing it. I was screaming and hollering for someone to 'please, help me.' No one came. I ended up having an accident. I had to be cleaned up of (urine and stool). I know when I have to go to the bathroom, I shouldn't be having accidents. Before I broke my leg, I could get up and down and do everything on my own. I can't do that right now. I ended up going home later that day. I now have a commode here in my living room. I would rather do that and be able to go to the bathroom when I need instead of waiting hours for help over there. On 5/31/23 at 12:40 PM, V2 (Director of Nursing) stated that on 5/23/23, V13 came to V2's office upset with R3's call light wait times. (V13) said that (R3) had waited over a half hour and that (V13) took (R3) to the bathroom herself. V2 stated this occurred around 8:30 AM, which was breakfast time. V2 stated, I could see longer (call light) wait times if it was around breakfast. On 5/31/23 at 1:13 PM, V6 (Social Service Director) stated that V6 was aware of R3 and V13's concerns regarding call light wait times. V6 stated R3 was offered to change rooms earlier in the week to a floor that wasn't as heavy and R3 declined due to the rooms being smaller. V6 stated on 5/25/23, V13 was very upset and went to V1 stating that V13 wanted to take R3 home. V6 stated R3 complained to V6 that it takes a while for staff to get to R3. V6 stated that V6 would normally complete a grievance or complaint form for R3 and V13's concerns but V6 overlooked that. V6 stated a whole investigation was completed after V13's concerns. V6 verified R3 discharged home the day of the 5/25/23 incident per R3's and V13's request. On 6/1/23 at 9:57 AM, V15 (Licensed Practical Nurse) stated that V15 walked into R3's room on 145426 Page 2 of 3 145426 06/01/2023 Pavilion of Ottawa 704 East Glover Street Ottawa, IL 61350

F 0550 5/23/23 as V13 was walking R3 back from the bathroom. Level of Harm - Minimal harm or potential for actual harm On 6/1/23 at 10:38 AM, V14 (Certified Nursing Assistant) stated the following: R3 was alert and oriented and able to make needs known; R3 was continent of urine and bowel; R3 required assistance to use the bathroom; and V14 assisted R3 in being cleaned up of urine and bowel in R3's bed. Residents Affected - Few On 5/31/23 at 3:09 PM, V1 (Administrator) stated that is the expectation that call lights are to be answered as soon as possible. V1 stated all staff was re-educated on 5/25/23, during the investigation into R3 and V13's call light concerns. V1 stated that no staff member should walk past a call light without going in to check on the resident. V1 stated that if the resident needs something that person cannot provide, the staff member should let the resident know they will get someone to help. V1 stated, If anyone is waiting 20 minutes or more, that is too long. 145426 Page 3 of 3