Health inspection·August 16, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure the call lights were answered in a timely manner to provide nursing care and services for two of three residents (Resident 1 and 2). Residents Affected - Few This failure had the potential to place two clinically compromised Residents (Resident 1 and 2) health and safety at risk when their activities of daily living were not met within a reasonable time. Findings: 1. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: muscle weakness, chronic respiratory failure (lungs cannot get enough oxygen into the blood), tracheostomy (incision in the throat to help you breathe), dependence on respirator (apparatus used to induce artificial breathing) and depression. During a review of the clinical record for Resident 1, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated May 22, 2023, indicated, Resident 1's score was a 15, which indicated Resident 1 was cognitively intact. In an interview with Resident 1, on July 25, 2023, at 2:27 PM, Resident 1 stated, It takes a long time for them to respond to the call light. Resident 1 then stated, It can take up to an hour. When I call for help. It's to change me. I can't change myself and it doesn't feel good when it takes an hour. 2. During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 2 was admitted on [DATE], with diagnoses which included: chronic respiratory failure, tracheostomy, dependence on respirator, and muscle weakness. During a review of the clinical record for Resident 2, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated June 11, 2023, indicated, Resident 2's score was a 15, which indicated Resident 2 was cognitively intact. In an interview with Resident 2 on July 25, 2023, at 2:39 PM, Resident 2 stated, Call lights? They're not too good time wise. You can push the button for the call light, and it will take a long time for them to answer it. It can take an hour. Push the call light and they don't come. I am calling them for medicine, pour the urinal out or something like that. I get frustrated. I press the button for my medication, and they don't answer. It happens a lot. It gets frustrating. It's ridiculous. I have to call the receptionist to get someone to come in here. We are on ventilators (breathing Page 1 of 2 055374 055374 08/16/2023 Upland Rehabilitation and Care Center 1221 E Arrow Hwy Upland, CA 91786

F 0684 machine). So, anything could happen if they don't come in to help us. Level of Harm - Minimal harm or potential for actual harm During a review of the clinical records, the care plans indicated: Residents Affected - Few 1. Resident 1's care plan dated June 27, 2022, indicated ADL (activity of daily living) self-care performance deficit related to limited mobility. Interventions: Bed mobility - totally dependent on staff for repositioning and turning in bed. Personal Hygiene- Requires total assistance with personal hygiene care. Toilet use - totally dependent on staff for toilet use. Encourage to use bell to call for assistance. 2. Resident 2's care plan dated June 7, 2023, indicated ADL (activity of daily living) self-care performance deficit related to impaired mobility. Interventions: Bed mobility- Requires staff participation to reposition and turn in bed. Toilet use- requires staff for toilet use. Encourage to use bell to call for assistance. During an interview with Licensed Vocational Nurse (LVN 1), on July 25, 2023, at 3:36 PM, LVN 1 stated, Call lights are meant to be answered as soon as possible. They should be answered in 15 minutes. Why? The resident could be in trouble, not breathing. The call lights should not be answered in one hour. It should be right away as soon as they see the call lights. During an interview with the Director of Nursing on July 25, 2023, at 4:27 PM, DON stated, Call lights: We are to answer then in adequate time, less then 5 minutes. Anyone can answer a call light. We answer the call lights to meet the resident's needs. It could be anything from changing or reposition or pain. They could be at high risk for skin breakdown or medication to lessen the pain, so it doesn't get worst. It definitely should not take us an hour to answer the call lights. The facility policy and procedure titled, Call Light/Bell dated October 2022, indicated It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: 1. Answer the light/bell within a reasonable time . 055374 Page 2 of 2