Health inspection·June 25, 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 the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). Residents Affected - Few This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) health and safety at risk when residents call lights were not answered promptly to assist with their activities of daily living. 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 that included cerebral ataxia (a disease with a symptom of an inability to coordinate balance, gait, extremities [fingers, hands, arms, legs]), and hypothyroidism (a condition that can make a resident feel tired, gain weight and be unable to tolerate cold temperatures). During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMSscreening tool to identify and monitor cognitive decline), dated April 28, 2024, indicated, Resident 1 ' s score was a 14, which indicated Resident 1 had no mental impairment. During an interview with Resident 1, on June 25, 2024, at 11:30 AM, Resident 1 expressed dissatisfaction with the response time to call lights. The resident stated that the response time varies, wait delays particularly during the PM shift, especially after 9:00 PM. The resident reported instances where she was not attended to for an hour or two. 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 that included heart failure (occurs when the heart muscle doesn ' t pump blood as well as it should. Blood often backs up and causes fluid to build in the lungs [pair of organs in the chest that supplies the body with oxygen and removes carbon dioxide from the body] and in the legs. The fluid buildup can cause shortness of breath and swelling of the legs and feet). 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 May 29, 2024, indicated, Resident 2 ' s score was a 12, which indicated Resident 2 had no mental impairment. During an interview with Resident 2, on June 25, 2024, at 11:35 AM, Resident 2 expressed concerns Page 1 of 2 055619 055619 06/25/2024 Las Colinas Post Acute 800 East 5th Street Ontario, CA 91764

F 0684 Level of Harm - Minimal harm or potential for actual harm regarding the response times to her call lights, stating that it often takes an excessive amount of time for the staff to respond. She mentioned resorting to using her telephone to contact the desk instead, finding it to be a quicker alternative. Furthermore, Resident 2 reported instances of delayed assistance while she was soiled. Additionally, the resident described occasions where it took one to two hours for the staff to address her call lights. Residents Affected - Few During a review of the clinical records for Reident's 1 and 2, the care plans indicated: 2. Resident 1 ' s care plan dated April 30, 2024, indicated Resident 1 has an activity of daily living deficit (tasks of everyday life – bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit, toileting, personal hygiene, and bathing) related to cerebral ataxia (a disease with a symptom of an inability to coordinate balance, gait, extremities [fingers, hands, arms, legs]), and hypothyroidism (a condition that can make a resident feel tired, gain weight and be unable to tolerate cold temperatures). Intervention: Call light within reach and answered promptly. 3. Resident 2 ' s care plan dated June 5, 2024, indicated Resident 2 has an actual activity of daily living deficit (tasks of everyday life)/mobility decline and requires assistance related to contractures. During an interview with DON on June 25, 2024, at 11:59 AM, I notified the DON regarding my findings of staff slow response to call lights are preliminary pending approval from my health facility evaluator supervisor. During a review of the facility ' s policy and procedure (P&) titled, Answering the Call Light, revised, October 2010, the P&P indicated The purpose of this procedure is to respond to the resident ' s requests and needs. 055619 Page 2 of 2