Health inspection·November 20, 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 interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was answered in a timely manner and helped in toileting by Certified Nursing Assistant (CNA) 4. Residents Affected - Few This failure had the potential to negatively affect Resident 1's physical comfort and psychosocial well-being. Findings: During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including osteoarthritis ( a joint disease, in which the tissues in the joint break down over time), heart failure (is a condition that develops when your heart doesn't pump enough blood for your body's needs), and edema (swelling caused by fluid trapped in your body's tissues). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 11/3/23, indicated Resident 1 had ability to makes self-understood and understand others. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity) with bed mobility, transferring, dressing, toilet use, and personal hygiene. During an interview on 11/16/23 at 2:00 pm with Resident 1's Representative ([RR] an individual chosen by the resident to act on behalf of the resident to support the resident in decision-making), RR stated at approximately 7 pm or 8 pm on 11/3/2023, Resident 1 asked Certified Nurse Assistant (CNA) 4 for assistance to the restroom. CNA 4 told Resident 1 that she has a diaper on, and she could go inside her diaper because she was almost done with work. RR stated Resident 1 informed her that it took 15-20 minutes for CNA 4 to respond after she pressed the call light. RR stated Resident 1 had become depressed (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) since being at the facility. During an interview on 11/17/23 at 11:20 am with CNA 2, stated that not answering call light in a timely manner and not responding to Resident 1's needs was considered neglect. CNA 2 stated residents can feel helpless, hopeless and feel facility staff does not care of their wellbeing. CNA 2 stated not answering the call light within 10 to 15 minutes would be considered not answering it in a timely manner. During an interview on 11/20/23 at 10 am with CNA 4, CNA 4 stated Resident 1 had put on her call light and when she went into the room, Resident 1 requested to be changed. CNA 4 stated she had Page 1 of 2 055531 055531 11/20/2023 Beachside Post Acute 22520 Maple Avenue Torrance, CA 90505

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few already cleaned Resident 1 twice during her shift (11 pm - 7 am shift). CNA 4 stated she told Resident 1 she had already clocked out for her break, and she would change her when she returned from her break. CNA 4 stated her break was 15 minutes. CNA 4 stated Resident 1 claimed it was longer than 15 minutes. CNA 4 stated she did not ask any other staff to assist Resident 1 at that time because her break was only 15 minutes. CNA 4 stated, Resident 1 should not have waited to be assisted with toileting or diaper changed. CNA 4 stated Resident 1 could have developed skin redness, a rash, or a bedsore by not being toileted in a timely manner and make her feel depressed or helpless. During an interview on 11/20/23 at 9:50 am with Director of Staff Development (DSD), DSD stated, it was not good for Resident 1 to wait to be changed, because she could have experienced skin breakdown, dignity issues. DSD stated neglect was not providing care or not providing assistance in a timely manner. During an interview on 11/20/23 at 10:30 am with Director of Nursing (DON), the DON stated, call light should be answered in a timely manner which was less than five minutes. The DON stated, by Residents 1's needs not being met in a timely manner she could develop a skin rash, bedsore, and feel embarrassed if she had to urinate or had a bowel movement in her incontinence brief (diaper). DON stated CNA 4 should have asked another staff to assist Resident 1, while she went on her break, to ensure Resident 1 did not have a delay in care. DON stated Resident 1 could have felt embarrassed, and ashamed. During an interview on 11/20/23 at 11:00 am with Administrator (Admin), the Admin stated, by Resident 1 not receiving care in a timely manner that could be considered neglect. The Admin stated neglect was failure to provide care, willfully and knowingly refusing to provide care. The Admin stated Resident 1 could have experienced a negative outcome such as skin breakdown, a feeling of hopelessness, and embarrassment. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2016, the P&P indicated Employees shall treat all residents with kindness, respect, and dignity. During a review of the facility's P&P titled, Abuse Prevention, dated 2018, the P&P indicated, The facility assures that residents are free from neglect by having the structures and processes to provide needed care and services. During a review of the facility's P&P titled, Dignity, dated 2021, the P&P indicated, Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents: for example. Promptly responding to a resident's request for toileting assistance. During a review of the facility's P&P titled, Answering the Call Light, dated 2010, the P&P indicated, The purpose of this procedure is to respond to the resident's requests and needs. 055531 Page 2 of 2