Health inspection·April 24, 2024

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for five of six residents (Resident 1, 2, 3, 4, and 6). The resident responsible party and confidential interview reported a pattern of delayed response to call lights and waiting for a long period of time for staff assistance. Additionally, there was no policy and procedure in place for the use of call light. These failures resulted in delayed provision of care and services for Resident 1, 2, 3, 4, and 6; and had the potential to negatively impact the resident ' s physical, mental, and emotional well-being. Findings: Review of Resident 1 ' s admission record indicated, was admitted to facility on 8/25/20 with diagnosis including lung disease, heart disease, borderline personality disorder (a mental illness that severely impact a person ' s ability to manage their emotions), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 3/2/24, indicated, no cognitive (thought process) impairment. During a telephone interview on 4/9/24 at 3:16 PM, Resident 1 ' s daughter stated, Call light issues are worst at night when mom has to wait for a long time, 35 minutes or more. No staff at front desk to answer calls. Resident 1 ' s daughter also stated that Resident 1 had UTI (urinary tract infection – an infection in any part of the urinary system) when she was left with wet diaper for a long time. During a confidential telephone interview on 4/10/24 at 9:54 AM, the Confidential Interview (CI) stated, he was aware of the daughter ' s issues and had witnessed delays in answering call lights during his visits at the facility. CI further stated, there is a monitor in front of the nurse ' s station showing the resident ' s room number and the number of minutes the light has been turned on. The CI confirmed and stated, observed during visits the call lights had been on for 35 minutes or so. During an observation on 4/10/24 at 3:09 PM, in resident ' s room, Resident 1 was sitting on the right side of the bed holding on to her call light, face was pinkish red in color. Resident 1 was Page 1 of 4 055968 055968 04/24/2024 Golden Heights Healthcare 35 Escuela Drive Daly City, CA 94015

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observed on O2 (oxygen) on at 2 liters per minute (LPM) via nasal cannula (a thin, flexible tube that wraps around your head, typically hooking around your ears) and had a bedside commode by the window. During concurrent interview on 4/10/24 at 3:10 PM, Resident 1 stated in an irritable tone that she had been calling for her medications and needed help to go to the bathroom. Resident 1 stated, she pressed her call light several times, but the nurse turned it off and went out of the room without helping her. I feel confused. I need help with my head. During further interview, Resident 1 stated, she turns her call light on and off at night because she needed help to go to the bathroom. Resident 1 added, it takes a long time for them to come and change her diaper especially at night time. Resident 1 expressed feelings of frustration and anger for ignoring her call at night time and stated that she gets more anxious when staff does not attend to her immediately. During an interview on 4/10/24 at 3:16 PM, at the nurse ' s station, Licensed Vocational Nurse (LVN) 1 stated he was aware of Resident 1 ' s call light had been on for a while. Resident 1 wanted another dose of her medication, but it was not time yet. LVN 1 stated that CNA assigned had been paged to turn off the call light. Review of Resident 1 ' s care plan, reviewed on 4/4/24, indicated, Focus: The resident has behavior problems: yelling and asking for help for no apparent reason. Episodes of cursing towards staff and restlessness . The care plan interventions indicated, Attend to the resident ' s need timely. Educate on call bell use and keeping within reach . During an observation on 4/10/24 at 3:21 PM, at the nurse ' s station, five staff were on the computer. A television (TV) monitor was observed in front of the nurse ' s station that displayed the following: [Facility Name] – Nurse Call Activity for all Rooms 104 – Routine call (00:20:52) OVERTIME STAT 201 – Routine call (00:09:24) OVERTIME STAT 116 – Routine call (00:05:17) 215 – Routine call (00:01:29) 200 – Routine call (00:01:14) During an interview on 4/10/24 at 3:25 PM, LVN 2 stated, call lights does not sound when turned on, instead the room number will show on the monitor (referring to the TV monitor in front of nurse ' s station) if the resident ' s call light is turned on. During further interview LVN 1 acknowledged room [ROOM NUMBER] (Resident 1) and 201 ' s (Resident 4) call light had been on for a while and stated, OVERTIME STAT means resident need to be attended as soon as possible. LVN 1 added, the receptionist will page the CNA assigned to the room shown on the monitor, will page again after 5 minutes if room number still shows on the monitor. 055968 Page 2 of 4 055968 04/24/2024 Golden Heights Healthcare 35 Escuela Drive Daly City, CA 94015

F 0725 During an observation on 4/10/24 at 3:26 PM, at the nurse ' s station, a television (TV) monitor in front of the nurse ' s station displayed the following: Level of Harm - Minimal harm or potential for actual harm [Facility Name] – Nurse Call Activity for all Rooms Residents Affected - Some 201 – Routine call (00:14:48) OVERTIME STAT 116 – Routine call (00:10:41) OVERTIME STAT 215 – Routine call (00:06:53) OVERTIME 200 – Routine call (00:06:38) OVERTIME 211 – Routine call (00:01:09) During concurrent interview, LVN 2 confirmed and stated, the call light monitor indicated Resident 4 and Resident 2 ' s call light had been on for more than ten minutes (OVERTIME STAT) and that CNA need to check on the residents right away. LVN 2 also confirmed and stated Resident 6 and Resident 3 ' s call light had been on for more than 5 minutes (OVERTIME) and need to be attended as soon as possible. During concurrent observation and interview on 4/10/24 at 3:27 PM, in room [ROOM NUMBER], three male residents were inside the room and were asked who pressed the call light, Resident 2 responded and stated, he pressed the call light because he needed a brief change. Resident 2 further stated, he had been waiting for someone to come and change his disposable brief. During concurrent observation and interview on 4/10/24 at 3:29 PM, Certified Nursing Assistant (CNA) 1 came to Resident 2 ' s room, turned off the call light, and stated, I will get my supplies. During further interview, CNA 1 stated, she was taking other resident ' s vital signs when she saw Resident 2 ' s call light was turned on. CNA 1 stated she cannot respond right away when she ' s providing care to another resident. It depends if I ' m doing something. CNA 1 added, she would tell the resident calling to wait until she ' s done with the other resident. During an observation on 4/10/24 at 3:34 PM, in front of Resident 4 ' s room, a CNA went inside the room, spoke to the resident, and turned the call light off. During an interview on 4/10/24 at 4:45 PM, the Director of Nursing (DON) stated, call lights need to be answered promptly. Call lights has no sound that is why the receptionist monitors the call light. The DON explained that the room number of the resident calling and the number of minutes since the call light was on will appear on the monitor, the receptionist will then page the assigned CNA to the resident ' s room. For room numbers with more than 10 minutes of waiting will turn red, the receptionist will page again the assigned CNA. During a follow-up interview on 4/24/24 at 3:15 PM, Receptionist 1 stated, the receptionists were tasked to monitor the call light on a screen at the nurse ' s station from 8 AM to 8 PM, then the nurses will monitor from 8 PM to 8 AM. Receptionist 1 explained, the resident ' s room number and the number of minutes will show on the screen when a call light is turned on. Receptionist 1 further stated, it (referring to the room number and minutes shown on screen) will turn red if the call light was on for 10 minutes, CNA will be paged to go to the resident ' s room, if light is still on, will 055968 Page 3 of 4 055968 04/24/2024 Golden Heights Healthcare 35 Escuela Drive Daly City, CA 94015

F 0725 page again a couple of times every five minutes. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/24/24 at 3:21 PM, the DON stated, Normally they have a buddy system, if the assigned CNA is not available, will send someone else to the room to check on the resident. Furthermore, the DON stated there was no policy and procedure specific for use of call light, only for paging system. Residents Affected - Some Review of facility ' s electronic mail (e-mail) document dated 4/25/24, indicated, the DON acknowledged and stated in the e-mail, I wasn ' t able to find another policy and procedure for answering call lights, as well as, for procedure to provide care as initiated via call light. During a telephone interview on 5/9/24 at 11:17 AM, the Administrator stated, staff need to respond to resident ' s call within five minutes, if with another resident, the pair they ' re working with or the charge nurse for that hallway will respond. The Administrator stated, the resident ' s room number and designated waiting time will change colors if call light was on for five to ten minutes or more. During further interview, the Administrator was not able to explain the meaning of each color changes and stated, I don ' t know what it means (referring to ' OVERTIME STAT ' shown on screen). Review of Resident Council for March 2024, dated 4/2/24, indicated, .Nursing concerns: .2. The call light sometimes takes a while to answer, especially at night . Review of facility ' s In Service Compliance Training Record titled ADLS/Communication with Family/Resident, dated 4/3/24, indicated, .Discussed topics included ADL, rounds every 2 hours, communication . 3. Make rounds every 2 hours. Before the end of the shift must make rounds. Report to charge nurse of any unusual observation . Review of facility ' s policy and procedure titled, Paging System, revised August 2006, indicated, .1. Our facility is equipped with a paging system for the purpose of paging personnel .to the resident rooms, to treatment areas . Call Lights – To announce call lights, press the ' Overhead Page ' button and say: ' Please answer call lights in rooms __ and __ (repeat x2). Thank you. ' Announce the call lights every 5 minutes. If it ' s already been 10 minutes or more, press the ' Overhead Page ' button and say: ' CNA to room __ (repeat x2). Thank you. ' ' CNA to rooms __ and __ (repeat x2). Thank you. ' Bathroom Call Lights – These are listed as priority call and shown in red. Be sure to announce these right away as they are typically more urgent . Review of facility ' s policy and procedure titled, Abuse and Neglect – Clinical Protocol, revised March 2018, indicated, .2. ' Neglect ' , as defined at 483.4, means ' the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. ' 055968 Page 4 of 4