Health inspection·January 16, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy to answer call lights promptly and failed to provide timely incontinence care to a resident. Residents Affected - Few This applies to 3 of 3 residents (R1, R3, R4) reviewed for call light response times in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, diabetes, atrial fibrillation, chronic kidney disease, heart disease, hypertension, difficulty walking, unsteadiness on the feet, morbid obesity, glaucoma, and dementia. R3's MDS dated [DATE] shows R3 is cognitively intact, requires setup with eating and oral hygiene, substantial/maximal assistance with bed mobility, and is dependent on facility staff for all other ADLs. R3 is always incontinent of bowel and bladder. R3's care plan entitled, At risk for alteration in skin integrity related to decreased mobility on a wheelchair, incontinent of bowel and bladder, and history of pressure ulcer initiated on April 19, 2024 shows multiple interventions revised on April 22, 2024 including, Keep skin clean and dry. R3's care plan entitled, The resident has an ADL self-care performance deficit r/t (related to) impaired mobility, weakness. Interventions updated on April 22, 2024 include, Toilet use assist - two staff assistance. On January 15, 2025 at 9:50 AM, R3 was lying in bed in his room. A strong odor of stool was present in the room. R3 said his incontinence brief was last changed at 5:00 AM before the night shift went home. R3 said, The last time I was changed was 5:00 AM today. Shortly after being changed, I had a bowel movement. I know not to press the call light during shift change or when they pass breakfast because no one will come. Around 7:30 AM or 7:45 AM, when they brought my breakfast tray, I told them that I needed to be changed. She said she would come back at 8:30 AM to clean me up. As of 9:50 AM, no one has come, and I have been sitting in poop for many hours. My butt is burning from sitting in poop this long. I press the call light and when no one comes, I just hold down the button continuously because I think that sets off an alarm somewhere else showing I really need assistance. When that doesn't work, I just start screaming out loud for help. They don't like that very much. During the conversation with R3, R3 pressed the call light to request assistance. No audible call light alarm could be heard, and the facility does not have illuminated lights over the resident's Page 1 of 3 146094 146094 01/16/2025 Eden Vista Burr Ridge 6801 Highgrove Boulevard Burr Ridge, IL 60527

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doorways to show which room is calling for help. A scrolling sign was located at the other end of the hallway, at the nurse's station, showing R3's call light was activated. V9 (LPN-Licensed Practical Nurse) was passing medications near R3's room. V9 did not stop administering medications to answer R3's call light. No CNAs were visible in the hallway. After 10 minutes and 25 seconds, V5 (SS) came to R3's room to ask if he needed help. R3 told V5 he needed assistance with incontinence care. V5 said she would find a staff member to assist R3. After a total call light response time of 13 minutes and 26 seconds, V8 (CNA) came to R3's room. R3 said he felt like he had waited too long to receive incontinence care. V8 said she was assigned to twelve residents and was busy providing incontinence care to two other residents and had not been able to answer R3's call light or attend to his need for incontinence care. At 10:09 AM, V8 (CNA) turned R3 to his right side and removed his incontinence brief. R3 had stool caked on the back of his legs, from his mid-thighs up to his buttocks. R3's entire buttocks was covered in stool. Stool had also leaked out of the top of R3's incontinence brief and had spread up R3's lower back. V8 (CNA) had to use multiple disposable wipes, and wiped multiple times over the same area to remove the stool because the stool was caked to R3's skin and did not wipe off easily. As V8 (CNA) used disposable wipes to clean stool from R3's legs, buttocks, and lower back, R3 cried out several times and said his skin felt sensitive and was burning. The skin on R3's buttocks was bright red in the areas where stool had been caked on his skin. 2. On January 15, 2025 at 9:27 AM, R4 was lying in bed in his room. R4 said, I have lived here less than a month. It takes them a very long time to answer call lights. One time it took over an hour. Forget calling for help around here. It takes too long for them to come to help. If I could do it myself I would, but obviously that's why I am here, because I can't do things for myself. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, hypotension, acute kidney failure, heart failure, atrial fibrillation, COPD (Chronic Obstructive Pulmonary Disease), hyponatremia, cognitive communication deficit, difficulty walking, and macular degeneration. R4's MDS (Minimum Data Set) dated December 29, 2024 shows R4 is cognitively intact, requires setup assistance with eating, substantial/maximal assistance with oral hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder. On January 8, 2025 at 10:32 AM, V5 (SS-Social Services) documented, Main topics discussed: Call response times: SS contacted [V17] (Daughter of R4) regarding a complaint about call times related to [R4]. The call light records were reviewed from the 1st to the 8th (January 2025). Average call response time was approximately 29 minutes. The longest recorded wait time was on the 6th (January 2025) from 7:00 AM to 10:46 AM, likely due to high call volume. Specific concerns: [V17] (Daughter of R4) noted concerns about two call times exceeding an hour. One confirmed incident was on the 6th (January 2025). An additional concern for the 5th reported by [V17] (Daughter of R4), though exact timing was unclear. Follow-up Actions: SS is actively working on resolving the issues and request that [V17] (Daughter of R4) reach out if she has further questions. On January 16, 2025 at 9:15 AM, V5 (SS) said, [R4's] family had concerns regarding call lights taking too long to be answered. I forwarded the concerns to [V2] (DON-Director of Nursing), and she said she would take care of it and make sure it didn't happen anymore. 146094 Page 2 of 3 146094 01/16/2025 Eden Vista Burr Ridge 6801 Highgrove Boulevard Burr Ridge, IL 60527

F 0677 Level of Harm - Minimal harm or potential for actual harm 3. The EMR shows R1 was admitted to the facility on [DATE] and was discharged to home on January 9, 2025. R1 had multiple diagnoses including, subluxation of C1/C2 cervical vertebrae, chronic osteomyelitis, displaced fracture of the second cervical vertebra, displaced posterior arch fracture of the first cervical vertebra, heart failure, rheumatoid arthritis, presence of bilateral artificial hip joints, dysphagia, spinal stenosis, and adjustment disorder. Residents Affected - Few R1's MDS dated [DATE] shows R1 had moderate cognitive impairment and was dependent on facility staff for all ADLs. R1 was always incontinent of bowel and bladder. R1's MDS continues to show R1 was admitted to the facility with an unstageable pressure ulcer. On January 14, 2025 at 1:06 PM, V1 (Administrator) reviewed the call light logs for the entirety of R1's stay at the facility. V1 said, There were call light response times over 45 minutes. On January 1, 2025 the call light log shows it took 85 minutes for [R1's] call light to be answered. On January 5, 2025 the call light log shows it took 55 minutes for [R1's] call light to be answered. The facility's policy entitled Call Light Use and Response, issued 1/14/19 with revision dated of 5/20/20 and 7/18/23 shows: Purpose: 1. To respond promptly to resident's call for assistance. 2. To assure call system in proper working order. Procedure: 1. Facility personnel will be aware of call lights. 2. Answer call lights promptly whether or not the staff person is assigned to the resident or not. 3. Answer call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room and attend to the resident needs . 146094 Page 3 of 3