Health inspection·September 18, 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, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for one of three sampled residents (Residents 1). Residents Affected - Few This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1) when Resident 1 ' s requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1 ' s admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted on [DATE], with a diagnosis that included history of falling and displaced intertrochanteric fracture of left femur (a type of fracture [break in the bone ] that occurs in the upper part of the thigh bone). During interview and observation with Resident 1 on September 18, 2024, at 12:32 p.m., Resident 1 stated, it is difficult to get assistance between 3:00 PM and 11:00 PM, and from 11:00 PM to 7:00 AM, they are left on their own as nobody comes. There have been instances when she called for help, but nobody showed up until the morning, she mentioned that sometimes she needs a change of diaper or pull-up and often don ' t receive the necessary help. The resident expressed that it varies among the nurses, with some showing care but not many. Ohers come and say they are the CNA (Certified Nursing Assistant - a healthcare professional who provides patient care under the supervision of licensed nurses) for the night, but the resident does not see them again. 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 August 29, 2024, indicated, Resident 1 ' s score was a 15, which indicated Resident 1 had no mental impairment. During a review of Resident 1's MDS Section G (Functional Status), dated August 29, 2024, the MDS Section G indicated, Resident 1 needed setup or clean-up assistance during eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During an interview with the staff, the Director of Staff Developer (DSD 1) on September 18, 2024, at 1:07p.m., DSD 1 indicated, call lights should be answered in a timely manner. Page 1 of 2 055693 055693 09/18/2024 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0684 Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s policy and procedure (P&P) titled Communication – Call System, dated January 01, 2012, the P&P indicated, Nursing staff will answer call bells promptly, in a courteous manner. Residents Affected - Few 055693 Page 2 of 2