Health inspection·May 31, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were treated with dignity and respect when: 1. Resident 1 had to wait three hours on a bedpan for assistance; and, 2. Resident 2's call light was not accessible when she was up in her wheelchair. These failures decreased the facility's potential to ensure residents received the care they needed and were treated with dignity and respect. Findings: 1. A review of an admission record indicated Resident 1 was admitted to the facility in April 2019 with diagnoses including difficulty walking, contracture (occurs when a muscle, joint or other tissues tighten or shorten causing a deformity) of right and left wrist, morbid obesity (chronic complex disease defined by excessive fat deposits that can impair health) and osteoarthritis (a degenerative joint disease causing joint stiffness, pain, and swollen joints) of right and left shoulder. A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/8/24, indicated Resident 1 did not have a memory problem, had impairment on both upper and lower extremities, and she was able to control her bladder and bowel. A review of Resident 1's Activities of Daily Living (ADL, activities related to personal care which includes toileting) care plan dated 3/8/24, indicated Resident 1 required assistance in personal hygiene due to weakness. The goals of the care plan included, Resident will be clean and dry . A concurrent observation and interview were conducted on 5/31/24 starting at 10:47 a.m., Resident 1 stated over the weekend, she was assisted on a bedpan at 9 a.m. and she was still on the bedpan until 12 p.m. Resident 1 further stated she had to call her daughter at 12 p.m. because staff had not responded to her call light and she was still on the bedpan. Resident 1 added, she pressed the call light half an hour after a bowel movement, and the Certified Nursing Assistant 2 (CNA 2) answered her call light. When Resident 1 informed CNA 2 she needed to be off the bedpan, CNA 2 told Resident 1 she will get another person to help Resident 1 since CNA 2 had work restrictions. Resident 1 stated she turned her call light on a third time when her assigned CNA did not come to assist her. Resident 1 further stated, I cried. I was extremely upset. Somebody should have noticed my call light. Resident 1 stated she felt, much less important .[and] .neglected just laying here. Page 1 of 3 055497 055497 05/31/2024 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 5/31/24 at 2:17 p.m., the CNA 1 stated all CNAs are responsible in answering the call lights. In an interview on 5/31/24 at 2:30 p.m., the CNA 2 confirmed she answered Resident 1's call light on 5/18/24. CNA 2 stated she told Resident 1's assigned CNA Resident 1 was almost ready to get off the bedpan. CNA 2 further stated she answered Resident 1's call light again, few hours later when lunch trays were getting picked up and Resident 1 was still on her bedpan. CNA 2 stated it was absolutely unacceptable for the light not being unanswered and Resident 1 was very upset and angry at the time. In an interview on 5/31/24 at 2:37 p.m., the Director of Nursing (DON) stated she was made aware of the incident of Resident 1's prolonged time on a bedpan. The DON's expectation was for staff to answer the call lights within 5 minutes. The DON further stated, If a call light goes on, I expect the CNA to answer the lights and to help the resident if they are not in a room helping another resident. 2. A review of an admission record indicated Resident 2 was admitted to the facility in November 2022 with diagnoses including secondary parkinsonism (symptoms include tremors and muscle movement), muscle weakness, and other abnormalities of gait and mobility. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had moderate memory problems impairment and was frequently incontinent of urine and stool. A review of Resident 2's ADL revised care plan, dated 5/16/24, indicated Resident 2 was at risk for altered ADLs (such as toileting) and required extensive assist. The care plan further indicated staff will ensure Resident 2's needs were met. A review of an admission record indicated Resident 3 was admitted on [DATE] with diagnosis including cerebral aneurysm (abnormal swelling or bulge in the wall of a blood vessel in the brain). Resident 3's MDS, dated [DATE], indicated she did not have a memory problem. During an observation on 5/31/24 starting at 9:28 a.m., the call light in Resident 2 and Resident 3's room was on to indicate assistance was needed. During an observation on 5/31/24 at 9:34 a.m., Resident 2 and Resident 3's call light was still on and multiple staff members were observed walking past the call light. In a follow up observation on 5/31/24 at 9:36 a.m., Resident 2 and Resident 3's call light was turned off by a staff member. During an observation on 5/31/24 at 9:41 a.m., a male staff member entered Resident 2 and Resident 3's room. Resident 3 informed him staff she pressed the call light for Resident 2. In an interview on 5/31/24 at 9:52 a.m., Resident 3 stated she had to turn on the call light for Resident 2 since staff were not answering her call light. During a concurrent observation and interview on 5/31/24 at 2:10 p.m. inside Resident 2's room, Resident 2 was self-propelling her wheelchair toward her bed and was unable to reach her call light. There was a transfer pole on the left side of Resident 2's bed and the call light cord was wrapped 055497 Page 2 of 3 055497 05/31/2024 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few around the left side rail of the bed. Resident 2 stated, 'I can't find my call light. When Resident 2 was asked why she used the call light, she responded in an upset tone, To get help to go to the bathroom and staff do not answer. A review of the facility's policy titled, Answering the Call light , revised December 2023, indicated, .Answer the call light as soon as possible .If you are uncertain as to whether or not you can fulfill the residents request, ask the charge nurse for assistance .If you have promised the resident you will return with .information .do so promptly. A review of the facility's policy titled, Activities of Daily Living , revised October 2023, indicated, Residents will be provided with care .services to ensure that their daily living (ADLs) are completed. A review of the facility's policy titled, Dignity , revised October 2022, indicated, .Staff shall promote dignity and assist residents as needed. 055497 Page 3 of 3