Health inspection·July 25, 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 interview and record review, the facility failed to ensure staff response/answer to Residents' call lights in a timely manor for three of three sampled Residents (Residents 1, 2, and 3).These deficient practice violated Residents 1, 2 and 3's rights, delayed in care and services and had the potential to affect Residents 1, 2, and 3's health.Findings:a) During a review Resident 1's, admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Morbid (Severe) Obesity, Hemiplegia (partial paralysis) and Hemiparesis (weakness or inability to move on one side of the body), and Neuromuscular Dysfunction (muscle weakness due to lack of nerve function) of Bladder.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/1/2025, the MDS indicated Resident 1's cognition (ability to understand) was normal. Resident 1 was dependent on staff for person hygiene before and after urinating or having a bowel movement and adjusting clothing. Resident 1 required maximal assistance rolling from left to right and moving from sitting to lying. Resident 1 received scheduled pain medications for occasional pain at an intensity of 7 on a scale of 1 to 10.During a review of Resident 1's Care Plan Report, dated 4/25/2025, the Care Plan indicated staff should keep the call light within reach and answer promptly due to the following health illnesses: diabetes mellitus (a disease that results in too much sugar in the blood), bowel and bladder incontinence (unable to control flow of urine), assistance with bed mobility (able to move freely), toileting (assist with using the bathroom) needs and fall prevention. The actions listed for staff assistance, dated 7/2/2024, included to remind Resident 1 to call for a bedpan, if unable to go to toilet, and to call for assistance with self-care.b) During a review Resident 2's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis (a chronic disorder of redness and swelling usually affecting the hands and feet), diabetes mellitus with diabetic polyneuropathy (a disorder that affects nerve function in multiple areas) , spinal stenosis ( the spaces inside the bones of the spine get too small), morbid obesity (too much body fat), and depressive episodes.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 has functional limitation in range of motion (full movement of a joint) of the upper and lower extremities and is always incontinent of bowel movements and is dependent on staff to maintain perineal (area of the body between the rectum and the sexual organs) hygiene, adjust clothing before and after voiding (urinating) or having a bowel movement, and getting on and off the toilet.During a review of Resident 2's Care Plan Report, dated 8/16/2025, the care plan indicated keeping the call light within reach and to answer promptly due to the following health illnesses: depression with suicidal thoughts, neuralgia/Neuritis (pain caused by damaged nerves) and migraine (intense head pain) Headaches, chronic pain syndrome, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down) , contractures (shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of Residents Affected - Some Page 1 of 2 055992 055992 07/25/2025 West Covina Healthcare Center 850 S. Sunkist Ave. West Covina, CA 91790

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some joints) of the left and right knee, and sleepiness side effects from antidepressant medications. Resident 2 is to use the call light to notify staff for any care the resident is unable to perform, for pain medications, assistance to the chair, and turning in bed.c) During a review of Resident 3's admission record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included disease of the pancreas (a large gland, in the belly, that helps digestion and regulates blood sugar), chronic kidney disease, abnormalities of gait (manner of walking), mobility, and end stage renal disease. During a review of Resident 3's MDS, dated [DATE], indicated Resident 3 was dependent on staff for toileting (assist with using the bathroom) and repositioning.A review of the Care Plan Report for Resident 3, dated 4/30/2025, indicated that Resident 3 should have a call light within reach and staff are to answer promptly to address Resident 3's symptoms of pain, bowel incontinence, assistance with toileting, and the risk of falling due to impaired mobility. During an interview on 7/25/2025 at 1:43 p.m., Resident 1 stated, after waiting 1 and 1/2 hours for staff to answer the call light, Resident 1 used a cell phone to call for help, then staff came to help Resident 1 in 15 minutes.During an interview on 7/25/2025 at 2:39 p.m., Resident 3 stated that staff do not respond quickly to call lights. Resident 3 stated quite a few times staff took a long time to provide personal hygiene. Resident 3 stated it is very upsetting and it's uncomfortable.During an interview on 7/25/2025 at 2:47 p.m., Resident 2 stated that call lights are not answered quickly and sometimes there there is only one CNA work on the weekend.During an interview on 7/25/2025 at 3:41 p.m., Resident 2 stated staff do not answer call lights on time. Resident 2 stated I was in pain for two hours, once holding my urine, while waiting for someone to answer my call light. Resident 2 stated I have gotten UTIs in the past due to waiting for call light help. Resident 2 stated when my curtain is pulled back, I can see their (staff's) hands turning it (call light) off without asking what we want.A review of the facility's Resident Council Minutes of Meeting, dated 3/26/25, indicated the call light response needs to improve and timely call light response is a concern of the residents.A review of the facility's policy and procedure titled, Residents Call System, dated September 2022, indicated calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. 055992 Page 2 of 2