Health inspection·June 26, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (RP) for two of three residents reviewed (Residents 1 and 2), when the residents had the change in condition and had to be transferred to the hospital. Resident 1 was transferred to the acute care hospital on April 29, 2023 and Resident 2 was transferred to the acute care hospital on May 6, 2023. This failure to notify the RP had the potential to delay the RP to advocate on behalf of Residents 1 and 2. Findings: On May 18, 2023, at 11:50 a.m., an unannounced visit was conducted to investigate an admission, transfer, and discharge issue. A review of Resident 1's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia. The record further indicated the resident has a conservator (an individual who handles the financial or daily life affairs of a conservatee, or a party deemed incompetent by a court). A review of Resident 2's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia. The record further indicated the resident has a conservator. On May 18, 2023, Residents 1 and 2's records were reviewed. The Nursing Progress Note record indicated: a. For Resident 1, on April 29, 2023, at 8:35 p.m., Licensed Vocational Nurse 1 (LVN) wrote, Resident sent to (name of hospital) .after calling 911 . , and b. For Resident 2, on May 6, 2023, at 1:00 p.m., LVN 1 wrote, .resident not acting her normal self .911 called at 13:11 .transferred resident .transported to (name of hospital) .at 13:36 . On May 18, 2023, at 2:20 p.m. a concurrent interview and record review were conducted with the Director of Nursing (DON). During review of the documentation made by LVN 1 for Resident 1 on 04/29/2023, and Resident 2 on 05/06/2023, the DON verified there was no documentation indicating the RP was informed of the change in condition and hospital transfer for both Resident 1and Resident 2. The DON stated the RP had to be contacted and notified of any resident's change in condition, need Page 1 of 2 055361 055361 06/26/2023 Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509

F 0580 for treatment, and hospital transfer. In addition,the DON stated the RP (conservator) had a 24 hour hot line. Level of Harm - Minimal harm or potential for actual harm A review of the undated facility document titled Resident Rights , indicated, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights .(a) Exercise of rights .(3) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf .(b) Notice of rights and services .(2) The resident or his or her legal representative has the right .to be fully informed in language that he or she can understand or his or her total health status, including but not limited to, his or her medical condition .(11) Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is- (B) A significant change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental, or psychosocial; status in either life-threatening conditions or clinical complications) .((D) A decision to transfer or discharge the resident from the facility . Residents Affected - Few 055361 Page 2 of 2