Health inspection·February 12, 2025

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 Activities of Daily Living ADLs policy and procedure for 4 of 10 sampled Residents (Resident's 1,2, 3 and 4) when: Residents Affected - Few 1. Resident 1 used call light to get staff attention for help and assistance and it takes a 1 hour to answer and NOC shift doesn't even come at all. 2. Resident 2 was left soiled for a long period of time on NOC shift. 3. Resident 3 used call light needed assistance due to feelings of low blood sugar and waited 3 hours long to get assistance. 4. Resident 4 needed assistance with ADLS and wait time was well over an hour or closer to shift change. This failure had the potential to cause (Resident 1,2,3, and 4) health and safety to be at risk for skin break down when their care needs were not met. Findings: During interview and Records Reviewed with (Resident 1,2, 3, and 4) indicates as followed: 1. During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: epilepsy (nerve activity in brain is disturbed causing seizures), diabetes type II (body does not produce enough insulin), cerebral infarction (blood flow in interrupted in brain, stroke). During observation and interview on February 04, 2025, at 10:40AM, with Resident 1, Observation 1of 2 side tables on other side of room, resident unable to access that table. Resident 1 states, I call for assistance and it takes them 1 hour to answer and NOC (night or overnight) shift they don't even come at all. 2. During review of Residents 2's admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses to include: fracture of left femur (broken thigh bone), diabetes type II (body does not produce enough insulin), history of falling. During an interview on February 04, 2025, at 10:57AM with Resident 2 (R2) R2 states, NOC shift I have sat in wet diaper for over an hour. Even my doctor said we are having trouble with NOC shift staff. Page 1 of 3 055708 055708 02/12/2025 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 - Few 3. During review of Residents 3's admission Record (general demographics), the document indicated Resident 3 was admitted to the facility on [DATE], with diagnoses to include: diabetes type II (body does not produce enough insulin), rhabdomyolysis (breakdown of muscle tissues leasing protein in blood), fibromyalgia (tender and painful joints), history of falling. During an interview on February 04, 2025, at 11:30AM with Resident 3 (R 3) R3 states, I have waited 3 hours on NOC shift to get assistance, but it can be on all shifts. You hear them talking out in the hall instead of assisting the residents. The nurse, I kept calling for help cause my sugar was low and they took too long to come check in on me. She finally came in and told me, Well I will check it when I come back , I told her I was not feeling good, my mom died because of this. 4. During review of Residents 4's admission Record (general demographics), the document indicated Resident 4 was admitted to the facility on [DATE], with diagnoses to include: above knee amputation left and right legs (absence of legs), diabetes type II (body does not produce enough insulin), hypertension (high blood pressure). During an interview on February 12, 2025, at 1:44PM with Resident 4 (R4) R4 states, Call lights, long waits are brought up in the council meetings. This happens to me at nighttime shift, over an hour for them to answer or they don't even come. They check on us until 4AM closer to the other shift coming in. 2 months complaining about this and it's still happening. I need assistance to get up, they don't want myself to get in wheelchair, but if they don't come, I have to get myself up. Where are they .everyone is sleeping. During an interview on February 12, 2025, at 1:11PM, with Certified Nursing Assistant CNA (CNA1) CNA1 states, PM and NOC shift I did have a resident crying she was left soiled at night, the resident is no longer here. I found 3 residents from yesterday and just in a brief no gown. Who the CNAs where I don't know. I do notify the Director of Staff Development (DSD) of issues; the PM or NOC nurses only check if the light is on for long periods. During an interview on February 12, 2025, at 2:35PM, with Director of Staff Development (DSD), DSD states, I have not had any complaints from residents about care, I do go talk to the residents. We do have some complaints, but not daily, we will always have some here or there. I have not had any complaints from the staff. If something is brought up, we have in-service with call light and educate the staff. As soon as we see it, we answer the call light. The residents should not be waiting over an hour to get assistance. Activities does let me know if any issues in the council meeting. During an interview on February 12, 2025, with the Administrator (Admin) Admins states, We have not heard of any issues with long waits or call lights from the residents. Expectation of Call lights are to answer within 5 minutes or less. There is a monitor on the nurse station with sound and monitor. It sends a message out if its more than 7 minutes. We use an outside source to monitor the call light system, have not heard anything from them. We have guardian angels staff goes around daily checking on residents. In the council meetings, we have not gotten any concerns, NOC shift nurse back station has a phone automated system, they have a phone and get a text. During a review of the facility's policy and procedure titled, Activities of Daily Living ADLs, Services to Carry Out revised [[DATE]], the policy and procedure indicated, It is the policy of 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 3 055708 02/12/2025 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0684 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Call Light revised [[DATE]], 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. 2.Turn off the call light/bell. 3.Listen to the resident's request/need.4. Respond to the request. If the item is not available or you are unable to assist, explain to the resident and notify the charge nurse for further instructions. Residents Affected - Few During a review of the facility's policy and procedure titled, Resident Rights revised [[DATE]], the policy and procedure indicated, It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality. 055708 Page 3 of 3