Health inspection·June 21, 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 their policy and procedure to ensure the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). Residents Affected - Few This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) health and safety at risk when residents were left soiled, and their activities of daily living were not met in a timely manner. Findings: 1. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which includes: stroke affecting the right side, visual loss, and muscle wasting. During a review of the clinical record for Resident 1, the history and physical, dated May 18, 2023, indicated This resident: has the capacity to understand and make decisions. In an interview with Resident 1, on May 24, 2023, at 6:07 AM, Resident 1 stated, I've sat here with a wet diaper for over two hours, and nobody came in to change me. It takes forever for them to come in and answer the call light. 2. During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 2 was admitted on [DATE], with diagnoses which includes: Depression and chest pain. During a review of the clinical record for Resident 2, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated March 8, 2023, indicated, Resident 2's score was a 15, which indicated Resident 1 did not have a mental impairment. In an interview with Resident 2 on May 24, 2023, at 7:55 AM, Resident 2 stated, I put on the call light, and they didn't come until the next shift. Weekends are really bad. I had diarrhea a couple weekends ago and I had to wait and an hour and a half a couple of times. I went three times that night. During a review of the clinical records, the care plans indicated: 1. Resident 1's care plan dated May 16, 2023, indicated Resident 1 has an activity of daily living (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056136 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Mesa Care Center 867 E. 11th St Upland, CA 91786 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)