Health inspection·August 31, 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 observation, interview, and record review the facility failed to follow Its policy and procedure to provide Activities of Daily Living Services (ADLS) and ensure call lights are answered in timely manner for 4 of 5 sampled residents. (Resident's 2,3,4, and 5). Residents Affected - Some This failure had the potential to place four clinically compromised Residents (Resident 2,3,4 and 5) health and safety at risk. When residents were left soiled, and their hygiene needs were not met. Findings: During a review of Resident 2's admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses to include, urinary tract infection (urine infection), multiple sclerosis (damage to nerves in brain and spinal cord), difficulty walking, hypertension (high blood pressure). During interview and observation on August 22, 2023, at 10:34 AM, with Resident 2, resident 2 states, The longest I have been in soiled bed is 7 hours on the night shifts, it's so uncomfortable. Some of the staff just does not care about the residents here. Call lights takes 2.5 hours the longest. I told my family member I need to get out of here, it's better for me to be home and get better myself than be here. Observation, resident getting teary eyed. During a review of Resident 3's admission Record (general demographics), the document indicated Resident 3 was admitted to the facility on [DATE], with diagnoses to include, metabolic encephalopathy (chemical imbalance in the brain), type 2 diabetes (body doesn't produce enough insulin, or resist insulin), hypertension (high blood pressure). During interview and observation on August 22, 2023, at 10:45 AM, with Resident 3, resident 3 states, I have bed sores, I've waiting 4 hours at night to get cleaned up. I was soaked and my wound bandaged came off and they left me like that until the treatment nurse did my dressing. After hours staff is not good and not professional, they take a very long time when I call for them, I'm sitting here wet. When they do come in, it's like we are not people, that's why I say unprofessional. I worry if my roommate leaves, I will really be on my own. Observation, facial expression worrisome. During a review of Resident 4's admission Record (general demographics), the document indicated Resident 4 was admitted to the facility on [DATE], with diagnoses to include, methicillin susceptible staphylococcus aureus infection MRSA (infection caused by bacteria), (abscess of right foot (accumulation of pus), hypertension (high blood pressure), difficulty in walking. Page 1 of 2 055708 055708 08/31/2023 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During interview on August 22, 2023, at 11:17 AM, with Resident 4, resident 4 states, I have waited hours once. I call for assistance, my neighbor, he has needed help and it takes them hours to get someone. This is in all shifts. He is not here right now but I see that problem here with the call lights/ the call system and having someone come and care for my roommate. During a review of Resident 5's admission Record (general demographics), the document indicated Resident 5 was admitted to the facility on [DATE], with diagnoses to include osteomyelitis to right ankle and foot (inflammation of bone caused by infection), cellulitis right lower limb (bacterial skin infection), type 2 diabetes (body doesn't produce enough insulin, or resist insulin), hypertension (high blood pressure). During interview on August 22, 2023, at 11:26 AM, with Resident 5, resident 5 states, At night I've called for the staff to help my roommate because he is soaked and he needs assistance, I must go look for them. I push the call light and I see the staff just walking around and no one answer and help change my roommate. During an interview on August 22, 2023, at 1:11 PM with the Director of Nursing (DON), DON states, the call lights and PM shifts, we are coming in and some staff are even working overtime because we do not want to use registry anymore, there is no accountability with registry. When asked, should residents be left in soiled briefs? No, they should not. During an interview on August 22, 2023, at 1:14 PM with the Operations Manager (OM), (OM) states, We just had a meeting the end of July, are focus is call lights. The residents should not be left soiled. We need to come in on other shifts to see what is happening. During a review of the facility's policy and procedure titled, Call light revised May 2021, the policy and procedure indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff .1. Answer the light/bell within a reasonable time, 3. Listen to the resident's request/need. 4. Respond to the request .5. Leave the resident comfortable . During a review of the facility's policy and procedure titled, ADL, Services to carry out revised January 2023, the policy and procedure indicated, It is the policy if this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities .2.Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain: good nutrition, grooming, personal hygiene, oral hygiene. 055708 Page 2 of 2