Health inspection·July 13, 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 observations, resident and staff interviews it was determined that the facility failed to respond to resident call bells in a timely manner for one of four call bells observed (Resident 1). Residents Affected - Few Findings include: Review of facility policy Call Lights: Accessibility and Timely Response dated 1/6/23, indicated the purpose is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or central location to ensure appropriate response. Review of admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/22/23, indicated the diagnoses of hip fracture, atrial fibrillation (irregular heart rhythm), and deep vein thrombosis (blood clot). Section G requires extensive assistance of two people for activities of daily living (hygiene, toileting, transferring). Review of Resident R1's care plan dated 6/23/23, indicated staff were to cue residents to call for assist with toileting as needed and keep call bell in reach. Interview on 7/13/23, at 8:40 a.m. Resident R1 indicated on more than one occasion she had to wait to go into or come out of the bathroom [ROOM NUMBER] minutes or longer for her call bell to be answered by staff. Observations on 7/13/23, at 10:32 a.m. Resident R1's bathroom call light was illuminated. Further observations showed Resident R1's bathroom call light continued for 16 minutes (10:48 a.m.). Interview on 7/13/23, at 10:33 a.m. Nursing Assistant Employee E1, who answered the light, stated I'm in here to help her. Interview on 7/13/23, at 10:33 a.m. Resident R1 stated I've been waiting so long, my rearend is stuck to the toilet. Observations on 7/13/23, at 1:16 p.m. Resident R1's bathroom call light was illuminated. Further observations showed Resident R1's bathroom call light continued for 16 minutes (1:32 p.m.). Interview on 7/13/23, at 9:54 a.m. Resident R2 indicated I have concerns with the number of staff, Page 1 of 2 395684 395684 07/13/2023 Concordia Lutheran Health and Human Care 134 Marwood Road Cabot, PA 16023

F 0558 Level of Harm - Minimal harm or potential for actual harm delays in giving and taking the bed pan (container used to collect urine or feces). I've waited as long as an hour. Interview on 7/13/23, at 9:59 a.m. Resident R3 indicated The staff are wonderful, but you have to wait as long as a half hour to get in the bathroom and another half hour to get back out. Residents Affected - Few Interview on 7/13/23, at 10:05 a.m. Resident R4 indicated The weekends are the worst for waiting a long time. Interview on 7/13/23, at 2:30 p.m. Nursing Home Administrator and Director of Nursing confirmed that the facility failed to answer the call bells in a timely manner for one of four call bells observed (Resident 1). 28. Pa. Code 211.12(d)(1)(2) Nursing services. 395684 Page 2 of 2