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.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145625
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Terrace
2829 South California Blvd
Chicago, IL 60608
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145625
If continuation sheet
Page 2 of 2
