Health inspection·June 1, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, review of facility concern logs, review of staff in-services, and review of Resident Council meeting minutes, the facility failed to ensure resident call lights were answered in a timely manner. This affected two (Resident #1 and #2) of seven residents reviewed for call lights. The facility census was 36. Residents Affected - Few Findings include: 1. Review of Resident #1's medical record, revealed the resident was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, rheumatoid arthritis, weakness, pain in left shoulder, tremor, Charcot's joint, right ankle and foot, muscle weakness, muscle wasting and atrophy, and anxiety. Review of Resident #1's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/15/23, revealed the resident was cognitively intact and required extensive assistance of two staff for bed mobility. No behaviors were noted within the assessment. Observation on 06/01/23 from 9:54 A.M. to 10:56 A.M. revealed Resident #1's call light had been activated for at least 62 minutes. Interview on 06/01/23 at 10:35 A.M. with Resident #1 revealed the resident was waiting on an aide to come and adjust the sheets and blankets underneath of her straightened out. The resident reported the aide was likely showering other residents and would come when she was able. Interview on 06/01/23 at 11:01 A.M. with Licensed Practical Nurse (LPN) #101 revealed LPN #101 had not realized Resident #1's call light was going off for so long. LPN #101 stated the aide who was assigned to the hall where Resident #101 resided had been on lunch break at that time, which is why LPN #101 went to check on the call lights that were activated. 2. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included weakness, respiratory failure, difficulty in walking, mild intellectual disabilities, cognitive communication deficit, unspecified psychosis, anxiety, need for assistance with personal care, and history of falling. Review of Resident #2's annual MDS 3.0 assessment, dated 05/10/23, revealed the resident was cognitively intact. The resident required extensive assistance of one staff for transfers and toileting. No behaviors were noted within the assessment. Observation on 06/01/23 from 10:28 A.M. to 10:50 A.M. revealed Resident #2's call light had been Page 1 of 2 366267 366267 06/01/2023 Altercare of Mayfield Village, Inc 290 North Commons Blvd Mayfield Village, OH 44143

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activated for at least 22 minutes. At approximately 10:37 A.M., Resident #2 began yelling and crying out someone please help me, ow, and help me. Resident #2 could be heard crying loudly from the nurse station located just off of the hall where the resident resided. Interview on 06/01/23 at 11:11 A.M. with Resident #2, revealed the resident had been in the bathroom waiting for assistance wiping and off of the toilet. Resident #2 reported it often took staff a long time to respond to her call light but could not relay an approximate amount of time. Interview on 06/01/23 at 11:01 A.M. with LPN #101 revealed LPN #101 had not realized how long Resident #2's call light was activated. LPN #101 reported whenever Resident #2 finished using the bathroom, she would begin crying out. LPN #101 stated the aide who was assigned to the hall Resident #101 resided on had been on lunch break at that time, which is why LPN #101 went to check on the call lights that were activated. Review of the concern logs for 03/01/23 through 05/31/23, revealed concerns regarding call lights were noted on 03/21/23, 03/29/23, 04/06/23, 04/07/23, and 04/11/23. The resolution provided for each occurrence was education and/or staff education. Review of the all-staff in-service dated 05/04/23 revealed staff were educated regarding call light response. Review of Resident Council meeting minutes dated 03/30/23, revealed a concern with call light response time was noted. This deficiency represents non-compliance investigated under Complaint Number OH00142463. 366267 Page 2 of 2