Health inspection·May 1, 2024

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 follow policy and procedure to ensure call lights were answered in timely manner to provide care and services for two of three sampled residents (Resident 1 and 2). Residents Affected - Few This failure had the potential to place a clinically compromised Residents (Resident 1 and 2) safety at risk. When residents were left soiled, and their activities of daily living were not met in timely manner. Findings: During interview and Records Reviewed with (Resident 1 and 2) indicates as followed: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnosis to include atherosclerosis of aorta ( fat and calcium built up in the inside wall of a large blood vessel), hypertension ( high blood pressure), Hyperlipidemia(high levels of fat particles in the blood), Major depressive disorder ( depressed mood, loss of interest), overactive bladder ( a problem with bladder function that causes the sudden need to urinate). During an interview on April 30, 2024, at 2:30pm with Resident 1, Resident 1 states My CNA 1 was irritated with me because 30 minutes after having my brief changed, I wet myself again, and she told me in a loud tone I ' m not going to change you again right now, I need to change another resident and I will be back after I ' m finished with her. Resident 1 also stated that it CNA1 took one hour to answer her call light. During review of Residents 2 ' s admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses to include Sepsis ( life threatening complications of infection), Pneumonia ( infection that inflames air sacs in one or both lungs which may fill with fluids), Muscle weakness ( lack of strength in muscles), type 2 diabetes mellitus ( body has difficulty controlling blood sugar), acute kidney failure ( kidney suddenly can ' t filter waste from blood), Hyperlipidemia (high levels of fat particles in the blood), and dysphagia (difficulty or discomfort in swallowing). During an interview on April 30, 2024, at 2: 45 pm with Resident 2, Resident 2 states, I waited more than an hour for my CNA1 to answer the call lights. I told CNA1 that I need my brief change and she told me that she ' s busy with another resident and that I need to wait until she ' s done. I waited for another hour, so I sat on my soiled brief for about 2 hours. And she placed my call lights where I could not reach for it. Page 1 of 2 055374 055374 05/01/2024 Upland Rehabilitation and Care Center 1221 E Arrow Hwy Upland, CA 91786

F 0684 Level of Harm - Minimal harm or potential for actual harm During an interview on April 30,2024 at 3:50 pm with the Assistant Director of Nursing (ADON). ADON stated that an alleged abuse was reported to them on April 26,2024 at 12:00pm, CNA1 was suspended on April 26,2024, until pending investigation. When ADON asked about the facility ' s policy on call lights and ADL ' s, ADON stated that call lights should be answered as soon as the staff can do so, and residents should not be left on their soiled brief for extended period of time. Residents Affected - Few During an interview on April 30,2024 at 4:15pm with Director of Nursing (DON). DON stated that call lights should be answered promptly by staff and residents should not be left on their soiled brief for hours. During a review of the facility ' s policy and procedure titled, , ADLS revised on November 2023, the policy and procedure indicated, Residents are given the appropriate treatment and services to maintain or improve his/her abilities .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the facility ' s policy and procedure titled, Call Light/Bell revised October 2023, the policy and procedure indicated, to provide the resident a means of communication with nursing staff the Steps in the procedure 1a. Answer the light/bell within a reasonable time. Leave the resident comfortable. Place the call device within resident ' s reach before leaving the room. 055374 Page 2 of 2