Health inspection·February 4, 2025

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. 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 protect and ensure the residents right to access and use of a telephone by failing to: Residents Affected - Few 1. Ensure Station B ' s portable phone was available forresidents to use. The portable phone was missing. 2. Ensure LVN 1 did not use her personal phone to contact residents ' families 3. Provide in services for staff including LVN1 that there was an additional cell phone available for residents to use in case the portable phone was not available (in use by other Residents, not working, or had a poor connection). These failures had the potential to negatively affect residents ' psychosocial wellbeing. Findings: During a review of Resident 1 ' s Face Sheet (admission record), the face sheet indicated the resident was admitted to Facility on 12/14/2018 and readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing ), Parkinson Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and acute respiratory failure (a life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels (hypoxemia) and high carbon dioxide levels (hypercapnia)). During a review of Resident 1 ' s History and Physical, dated 7/15/2024, the History and Physical (H&P) indicated Resident 1 had the capacity to understand and make decisions, sometimes. The H&P indicated Resident Representative (RP) 1 and Resident Representative (RP) 2 are Resident 1 ' s Responsible party. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/28//2025, the MDS indicated Resident 1 ' s cognition was severely impaired (significant loss or reduction in a person ' s cognitive abilities, such as memory, reasoning, problem-solving, attention, and language, which severely interfered with the individual ' s ability to function normally in everyday life, including performing basic tasks, making decisions, or communicating effectively. During an interview on 2/4/2025 at 10:46 AM with Resident 1 ' s RP 2, RP 2 stated the facility does Page 1 of 3 055288 055288 02/04/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0576 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not have a telephone available for residents to use in their room. They haveportable phones, but the phones are not functioning properly. RP 2 stated that this has been going on for some time now, approximately eight plus years. RP 2 stated when they would call the facility they had to wait on hold for a very long time, because they were being transferred to every station and then the call would drop because the connection for the wireless phone was not strong enough to hold on to the call. If the call was not being dropped, the wireless phones would not work or was broken. RP 2 stated the latest incident took place on Sunday on 1/26/2025 after contacting the facility and speaking to three different nurses and waiting approximately 45-minutes, the call dropped. RP 2 stated the facility informed RP 2 that Station B ' s (Where Resident 1 is located) phone was broken and only Station A and Station C have a phone available. During an interview on 2/4/2025 at 11:25 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she works on Station B and was assigned to Resident 1. LVN 1 stated there were three (3) stations and each has a portable phone for residents to use onStation A, B, and C. LVN 1 stated when family calls the receptionist transfersthe call to the desk phone at the nursing station. Staff then transfer the call to the portable phone and take it to the resident ' s room. LVN 1 stated there are many times that the portable phones are not working, have a poor connection, or not available (other resident using it, at times when the transferred call drops. Sometimes the family calls and tells her they were on the phone for a long time and when she transfers the call to theportable phone and then the call drops. LVN 1 further stated she would use her personal cell phone for resident families whenever the portable phone was not available or not functioning properly. LVN 1 stated it is important for the resident to talk to their family, so they do not feel abandoned. LVN 1 stated she is not aware of any other cell phone or portable phones available that residents can use. During an observation on 2/4/2025 at 12:10 PM of station B, a base of a portable phone was observed at the nursing station but there was no portable phone observed. During an interview on 2/4/2025 at 12:15 PM with RN1, RN 1 stated she could not find Station B ' s portable phone and did not know where it was. RN 1 stated Station A ' s portable phone does not work on station C and Station C ' s portable phone does not work on Station A because it is far from the base which is in each station. RN 1 stated Station A and C ' s portable phones do work in some of the rooms on Station B, but at times the reception is not good. During an interview on 2/4/2025 at 12:36 PM with the DON, the DON stated Station B ' s portable phone was missing (could not recall when) and currently there are only two portable phones available to use between 94 residents. The DON stated thefacility should accommodate Resident ' s needs and a phone should be available to use for Residents and should be available when family calls to contact residents. The DON stated it is the resident ' s right. The DON stated staff are not allowed to use their personal phone to contact family. The DON stated there is a facility cell phone available for staff to use in case the portable phone is not available. The DON stated she cannot provide any document that an in-service was provided for staff indicating there is cell phone available to use if the portable phone was not functioning. During an interview on 2/4/2025 at 1:06 PM with the ADM, the ADM stated the Station B phone wasmissing and only two portable phones are available to use for residents, in addition to thefacility cell phone. The ADM stated staff are not allowed to use their personal phone to call the family and they should limit the use of the personal cell phone at thefacility. TheADM stated she does not have any proof that in-services were provided to staff about using the facility cell phone in case portable phone not available. 055288 Page 2 of 3 055288 02/04/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0576 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/4/2025 at 2:35 PM with LVN 2, LVN 2 stated she received a call from Resident 1 (RP 1), and reported to her that the Station B portable phone was missing and if the facility ' sportable phone was not available, she would use her personal cell phone to contact RP 1. During a review of the facility ' s Policy and Procedure (P&P) titled Resident Access to a Telephone, approved on 8/16/2021, indicated Residents are provided with reasonable access to a telephone where calls can be made without being overheard. Telephones in staff offices or at nurses' stations do not meet the provisions of this policy. The resident must be provided access to a private space for telephone calls. Reasonable Access includes placing telephones at a height accessible to residents who use wheelchairs, and adapting telephones for use by residents with impaired hearing. Make telephones available to residents for placing and receiving telephone calls without being overheard. This may include use of cordless telephones or having phone [NAME] in the resident's room. Do not locate telephones in areas that are locked or otherwise unavailable during evenings, weekends, or holidays. Provide assistance to residents who need or request help with getting to or using the telephone. Any requests for assistance in telephone access should be documented in the medical record. Document in the electronic health records system. If the electronic health records system is not available, the documentation can be accomplished in paper form. During a review of the facility ' s P&P titled Personal Telephone Calls to/From, Employees, Social Media Use, approved on 11/13/2024, indicated The company shall limit the use of personal cell phone and personal telephone calls during work hours. The company shall check the state specific regulations on personal telephone calls to/from employees and social media use while at the workplace. Staff shall not make or receive personal telephone calls in their work area. Employees may request authorization from supervisors to use personal cell phones or facility's telephones during working hours for the purpose of making calls to latch-key children, babysitters, day care providers, teachers and family members to inform them of schedule changes and other essential business. Supervisors shall grant reasonable requests of this nature. Employees shall make every attempt to limit personal phone calls to meal periods and rest breaks. Cell phones owned by the facility and issued to employees shall be used for work-related purposes only. 055288 Page 3 of 3