Health inspection·February 8, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation and record review the facility failed to ensure reasonable accommodations of residents needs by failing to ensure nurse calls are assessable to the residents and answered in a timely manner in 7 (R1, R2, R3, R6, R7, R8, R9) of a sample of 20 residents. Residents Affected - Some Findings include: On 2/7/25 at 10:25am R2 was observed in his room in bed. R2 had a strong urine odor. R2's nurse call was on the floor and not in reach. R2 stated they don't answer the nurse calls when I pull it. When they do it takes a long time. This happens on all shifts. I need to be changed now. On 2/7/25 at 10:33AM R3 stated they don't answer the nurse calls. I press the button and it takes a very long time for someone to show up to give me assistance. R3 pushed the nurse call button during the interview. The room light outside the room lit. The light next to the 3rd floor nurses station on the ceiling lit. Two nurses, V3 (Registered Nurse/RN) and V4 (Licensed Practical Nurse/LPN) were at the nurses station conducting computer and paper work. The nurse call system registers at the nurse station desk phone. A screen on the phone notifies as to what room has been activated for a nurse call. The phone face screen was covered by a sheet of paper and this screen was not visible. Both V3 and V4 were not aware that the nurse call was activated and continued desk duties. No other staff were at the nurses station. At 10:43am no staff had answered the nurse call that R3 activated at 10:33AM. Surveyor notified both V3 and V4 and both were asked why the call had not been answered. Both stated they were not aware that the call was activated. On 2/7/25 at 10:35 V3 (RN) stated I didn't know R3 needed assistance. V3 stated I don't know who put the paper over the phone nurse call activation screen. The phone screen is how we know when the nurse call has been activated and who's room it is. I don't know where the CNAs (Certified Nursing Assistant) are right now. I think they are in residents rooms providing care. On 2/7/25 at 11:55AM R1 stated they don't answer the calls half the time. Sometimes they answer and say they will be back and never return. I want to get up out of bed and they don't return. A CNA came into my room one time and told me they turned the nurse calls off. On 2/7/25 at 10:15 AM R7 stated they don't answer the nurse call half the time I pull it. On 2/7/25 at 10:35AM R8 stated hell no they don't answer the nurse call. One CNA told me they shut off the nurse call system. so they don't have to answer. On 2/7/25 at 10:45AM R6 stated they never answer the nurse calls. Page 1 of 2 145625 145625 02/08/2025 California Terrace 2829 South California Blvd Chicago, IL 60608

F 0558 On 2/7/25 at 12:14PM R9 stated they don't answer the nurse call. I have to call the front desk on my Level of Harm - Minimal harm or potential for actual harm cell phone to get a nurse in here. Sometimes they answer my phone sometimes not. Residents Affected - Some On 2/8/25 at 9:45AM V1 (Administrator) stated I am not aware that staff covered the nurse call system phone screen on the 2nd floor. I am not aware that the nurses in the station ignored the nurse call when it was activated. All staff are supposed to answer the call right away. Nurses are supposed to answer the calls if CNAs are not present. We have a call light policy that is supposed to be followed by all staff. Facility policy titled Call Light states includingPurpose: To respond to residents requests and needs in a timely manner. Equipment: Functioning Nurse Call System. Policy: All call lights will be answered by any staff within their scope of practice. Standards: 1.All residents shall have the nurse call light system available and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered. 4. Requests shall be responded to in a courteous and professional manner. Procedure: 1 Answer light (signal) promptly. 2.Be courteous when entering room. 3.Turn off call light 4.Listen to residents request. Do not make the resident feel that you are too busy to help. 145625 Page 2 of 2