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. Page 1 of 4 146143 146143 07/31/2024 Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133

F 0677 Level of Harm - Minimal harm or potential for actual harm The call light monitoring device at the nurse's station showed R12's call light had been illuminated for 10 minutes. The call light also made an audible sound which could be heard at the nurse's station. V15 (Nurse), V16 (Nurse), and V6 (CNA) were sitting at the nurse's station while the call light was illuminated and sounding, and none of the staff attempted to answer the call light, while having a personal conversation with each other. No staff was present in R12's room. Residents Affected - Some R12's MDS dated [DATE] shows R12 is cognitively intact, requires set up assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with lower body dressing, and is dependent on facility staff for toilet hygiene. R12 is always incontinent of bowel and bladder. R12 uses a walker or wheelchair for mobility. 3. On July 25, 2024 at 11:40 AM, R9 was sitting in her room. R9 said she is the Resident Council President. R9 said, It can take 45 minutes or longer for call lights to be answered. [V17] (Director of Entertainment) comes to the Resident Council meetings and takes notes. [V17] knows that we are all complaining about the call lights, but they don't do anything about it. It never changes and nothing ever gets done about it. Month after month we complain about the call lights and month after month nothing changes. It is frustrating. The EMR shows R9 was admitted to the facility on [DATE] with multiple diagnoses including, heart failure, COPD (Chronic Obstructive Pulmonary Disease), atrial fibrillation, PVD (Peripheral Vascular Disease), soft tissue disorder, presence of cardiac pacemaker, major depressive disorder, idiopathic progressive neuropathy, and osteoarthritis. R9's MDS dated [DATE] shows R9 is cognitively intact, requires setup assistance with eating, oral hygiene and personal hygiene, supervision with toilet hygiene, bed mobility, and transfers between surfaces, and partial/moderate assistance with showering and dressing. R9 is occasionally incontinent of urine, and frequently incontinent of stool. The Resident Council meeting minutes dated April 17, 2024 shows V17 (Director of Entertainment) facilitated the meeting, and R9 and five guests were present. The meeting minutes show multiple concerns discussed during the meeting, including: The guests would like to see the nurses to do more rounding and assist nursing aides with call lights when needed. The Resident Council meeting minutes dated May 22, 2024 shows V17 (Director of Entertainment) facilitated the meeting, and R9 and nine guests were present. The meeting minutes show multiple concerns discussed during the meeting, including: Guests had call light concerns. The Resident Council meeting minutes dated June 19, 2024 shows V17 (Director of Entertainment) facilitated the meeting, and R9 and five guests were present. The meeting minutes show multiple concerns discussed during the meeting, including: The guests have call light concerns. 4. On July 24, 2024 at 6:09 PM, R4 said she spoke to someone at the facility regarding the call light response time. R4 said, The woman was very proud to say if your call light is answered within 20 minutes, that is good for us. Well, I am glad it is good for them, but it is not good for me. If I was pressing the call light, it was because I needed help and something like needing to use the bathroom can't wait 20 minutes. The EMR shows R4 was admitted to the facility on [DATE] and was discharged to her home on March 27, 2024. R4 did not return to the facility. R4 had multiple diagnoses including, left lower leg 146143 Page 2 of 4 146143 07/31/2024 Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133

F 0677 fracture, overactive bladder, diabetes, history of falling, hypertension, depression, and osteoporosis. Level of Harm - Minimal harm or potential for actual harm R4's MDS dated [DATE] shows R4 was cognitively intact, was able to eat independently, required supervision with oral hygiene and personal hygiene, and required partial/moderate assistance with toilet hygiene, showering, lower body dressing, bed mobility, and transfers between surfaces. R4 was always continent of bowel and bladder. Residents Affected - Some 5. The facility's Resident Grievance Form dated May 29, 2024 shows V13 (Spouse of R13) had the following grievance: Wife was unhappy related to response time of less than 18 min. (minutes). Stated [R13] had feces everywhere. On July 30, 2024 at 2:25 PM, V13 (Spouse of R13) said, [V13] had dementia and could not use the call light. I came to the facility, and he was covered in feces. His was lying in a soaked [incontinence brief], his gown was soaked, his sheets were soaked, and even his socks were wet. I pressed the call light for him so they would come and clean him up, and they didn't come. It took almost 20 minutes for someone to come. The EMR shows R13 was admitted to the facility on [DATE] and discharged from the facility on June 22, 2024. R13's MDS dated [DATE] shows R13 had clear speech and was able to express needs. R13 had severe cognitive impairment, required supervision with eating and oral hygiene, partial/moderate assistance with bed mobility and transfers between surfaces, and was dependent on facility staff for toilet hygiene, showering, lower body dressing, and personal hygiene. R13 was occasionally incontinent of urine, and frequently incontinent of stool. 6. The facility's Resident Grievance Form dated April 9, 2024 shows V14 (Son of R14) had the following grievance: Call light concern and difficulties reaching floor staff via phone. On July 30, 2024 at 2:33 PM, V14 said, My mom (R14) was calling us on the telephone and saying no one is answering my call light. No one is coming to help me. We tried to call the facility to get help for her, and no one was answering the telephone. We live close by, so my wife drove over there. She walked in, and the person who answers the phone at the front desk was sound asleep. This was about 7:00 PM. My wife took a picture of the person and sent it to me. My wife mentioned something to the nurses up on the floor about the person sleeping, and they said they don't blame the person because she had worked a 12-hour shift. I filed a grievance with the facility. I told the Director of Nursing and forwarded the picture to him. [R14] always complained about the call lights taking a long time, and we always saw a lot of call lights going off when we went to the facility. It just felt like no one cared. The EMR shows R14 was admitted to the facility on [DATE] and discharged from the facility on April 24, 2024. R14's MDS dated [DATE] shows R14 was cognitively intact, was independent with eating, required supervision with oral and personal hygiene, and substantial/maximal assistance with toilet hygiene, showering, lower body dressing, bed mobility, and transfers between surfaces. R14 was always incontinent of bowel and bladder. 146143 Page 3 of 4 146143 07/31/2024 Ignite Medical Hanover Park 2000 West Lake Street Hanover Park, IL 60133

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility's policy entitled Call Light - Ability to Use revised/reviewed on 01/2024 shows: General: to provide guidance on use of call light for residents. Procedure: 1. The call light system is provided as a tool for residents to communicate with staff. 2. Residents will be evaluated for ability to use call light on admission, quarterly and annually. 3. If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) will be provided. 4. If residents are determined to be cognitively unable to use call lights, residents will be monitored for needs by staff members during rounds and while delivering care.6. Staff members will acknowledge and respond to the call light by entering the resident's room and determining and assisting with the resident's needs. 146143 Page 4 of 4