Health inspection·June 15, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interviews and record reviews, the facility failed to ensure that call lights are answered in a timely manner per policy. This deficiency affects four (R1, R12, R13 and R14) of four residents reviewed for accommodation of needs. Findings include: 1.) R1 was admitted on [DATE] with diagnoses of Displaced Fracture of Base of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Difficulty in Walking, Not Elsewhere Classified; Unsteadiness on Feet; Need for Assistance with Personal Care and End Stage Renal Disease. R1's MDS (Minimum Data Set) dated 05/25/23 under Section C indicated that her BIMS (Brief Interview for Mental Status) score is 15 which means intact cognition. R1 was discharged to home on [DATE]. According to concern form dated 05/28/23, she (R1) complained of poor call light response during night shift. V1 (Administrator) stated during interview on 06/13/23 at 2:59 PM that R1 was talking about call light responses that she waited for longer periods of time because she wanted staff to respond quicker. V1 continued, It happened more on the night shift. She mentioned that night shift did not respond quicker. I did education on call light. 2.) R12 was initially admitted in the facility on 05/23/23 with diagnoses of End Stage Renal Disease; Shortness of Breath; Difficulty in Walking, Not Elsewhere Classified and Unsteadiness on Feet. On 06/14/23 at 12:26 PM, R12 was observed in her room, alert and oriented. Her call light was observed within her reach. R12's BIMS score is 15 which means intact cognition, per MDS dated [DATE]. R12 was asked regarding issues on call lights. R12 stated, This early morning, I pushed the call light around 3, 3:30 AM and no one came to my room until around 5:00 AM. I waited for an hour and a half to two. No staff cared to respond to my call light. Concern form dated 05/29/23 documented R12 complained that she was not satisfied with the call light responses from staff. 3.) R13 was admitted with diagnoses of Nondisplaced Zone 1 Fracture of Sacrum, Subsequent Encounter for Fracture with Routine Healing and Dependence on Supplemental Oxygen. On 06/14/23 at 12:35 PM, R13 was observed in her room, lying in bed, on continuous oxygen at 3 lpm (liters per minute) via nasal cannula. Her call light was within her reach, by bedside rail. Per MDS dated [DATE], her BIMS score is 9 which means moderately impaired cognition. R13 was asked if she has any concern with staff responding to her call light. R13 stated, It was during night shift, staff don't come when I pushed the call light. I need to go to the bathroom, but no one came so I just got up and walked to the bathroom. And I have this oxygen in me. It was 2:30 AM that I used my call light, but no one checked on me and came to my room until next shift came. According to concern form dated 06/12/23, she (R13) complained that it took too long for staff to respond to her call light. Page 1 of 2 145701 145701 06/15/2023 Bella Terra Streamwood 815 East Irving Park Road Streamwood, IL 60107

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4.) R14 was admitted on [DATE] with diagnoses of Other Specified Arthritis, Left Shoulder, and Other Muscle Spasm. On 6/14/23 at 12:41 PM, R14 was observed in room, lying in bed, alert, oriented and verbal. Her call light was at bedside and within her reach. R14 was asked if she must wait longer time for staff to come to her room when she pushed her call light. R14 replied, Sometimes staff come to my room when I pushed the call light but a lot of times they don't. I waited and waited for an hour or more. It depends on who the CNA (Certified Nurse Assistant) is assigned to me. R14's MDS dated [DATE] indicated a BIMS score of 9 which means moderately impaired cognition. On 06/14/23 at 12:57 PM, V2 (Director of Nursing) was asked regarding call light response time. V2 replied, All staff is responsible to respond to call lights. It should be responded within 5-10 minutes, the acceptable time because some staff or CNAs are still assisting other residents. I expect that anybody who could see the call light on, it should be responded. Even when staff is walking the hallway, call light should be responded in a timely manner. Facility's policy titled Call Light Policy revised date 7/27/22 stated in part but not limited to the following: Policy Statement: It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. The facility also ensures that the call system is in proper working order. Procedures 1. Facility shall answer call lights in a timely manner. 145701 Page 2 of 2