Health inspection·July 31, 2024

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 promptly respond to residents' call lights when residents require assistance with ADLs (Activities of Daily Living). Residents Affected - Some This applies to 6 of 6 residents (R4, R9, R10, R12, R13, R14) reviewed for timely call light response and ADL care in the sample of 14. The findings include: 1. On July 25, 2024 at 11:20 AM, R10's call light was illuminated over the doorway of his room. A call light monitoring device similar to a telephone with a display screen, located at the nurse's station, showed all resident room numbers with call lights illuminated on the same unit as R10 resided. The call light monitoring device showed R10's room number and the time of 17 minutes, 26 seconds displayed. As the call light continued to go unanswered, the time continued to increase. No staff answered R10's call light. Upon entering R10's room, R10 was lying in his bed. R10's left foot and lower leg were wrapped in a thick dressing and elastic bandage. R10 had two urinals on the table over his bed. One urinal was filled with 1000 ml (Milliliters) of clear, yellow liquid, and the other urinal had 500 ml of clear yellow liquid in it. R10 said he had pressed the call light approximately 20 minutes earlier because he had filled his urinals with urine and needed them removed from his bedside table and emptied, and he also wanted to get out of bed, which required a mechanical lift due to his recent left foot surgery. R10 said, It takes longer than it should to answer the call light. One time they put me on the bed pan and it took one and a half hours to get someone to get me off the bed pan. After approximately five additional minutes of R10's call light being illuminated, V7 (CNA-Certified Nursing Assistant) came to R10's room to answer R10's call light. V7 said, A lot of residents complain about how long it takes to answer the call lights. The EMR (Electronic Medical Record) shows R10 was admitted to the facility on [DATE]. R10 has multiple diagnoses including, osteomyelitis of the left ankle and foot, difficulty walking, lack of coordination, reduced mobility, morbid obesity, diabetes, heart failure, depression, anxiety, Parkinson's disease, and diabetic ulcer of the foot. R10's MDS (Minimum Data Set) dated July 19, 2024 shows R10 has moderate cognitive impairment, requires setup assistance with eating and oral hygiene, partial/moderate assistance with bed mobility, substantial/maximal assistance with toilet hygiene, showering, and lower body dressing, and is dependent on facility staff for transfers between surfaces. R10 is occasionally incontinent of bowel and bladder. 2. On July 25, 2024 at 11:20 AM, the call light for R12's room was illuminated over the doorway. (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 4 Event ID: 146143 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 146143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133 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)