Health inspection·October 19, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report a change of condition and document in the medical records for one of four clinically compromised residents (Resident 1). This has the potential to exclude the family and responsible party of (Resident 1) to actively participate in the plan of care related to the resident's change of condition. Findings: During a review of Resident 1 ' s Face Sheet (general demographics) on October 19, 2023, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included Hypertension (high blood pressure), Hyperlipidemia (high concentration of fats in blood), Hypothyroidism (low thyroid gland activity), Schizophrenia (mental illness that affect the way a person thinks, feels and behaves), Bipolar Disorder (mental illness by alternating periods of elation and depression). During a review of Resident 1 ' s Face Sheet indicated, Responsible Party, Second Contact [Name of daughter with phone number provided], Third Contact [Name of daughter with phone number provided]. During a review of Resident 1 ' s History and Physical Examination (H&P), the H&P dated February 2023, indicated, .This resident (Resident 1): .B. does NOT have the capacity to understand and make decisions. Reason: A&O x1 (Alert and oriented x 1). During a concurrent interview and record review on October 19, 2023, at 12:30 PM, with the Assistant Director of Nurse (ADON), the Physician Order dared October 11, 2023, indicated, May transfer to [Name of hospital] for Eval Due to episodes of increased confusion Decreased PO (by mouth) intake with 7 days bed hold. During a concurrent interview and record review on October 19, 2023, at 12:30 PM, with the Assistant Director of Nurse (ADON), Departmental Notes, dated October 11, 2023, by a licensed vocational nurse (LVN) indicated, .Res (Resident) pick up by arrange transportation arrange by the SSD (Social Services Director) to LADMC (Los Angeles Downtown Medical Center) for eval. Res awake, alert, no c/o (complaint of) pan noted. All needs attended well. The ADON, the ADON stated, When there is a change in condition and a transfer to the hospital, the responsible is notified of the change in condition and the transfer to the hospital. She further stated she expected the nurse to have notified the responsible party and recorded in the resident ' s medical records. During a review of the facility ' s policy and procedure (P&P), titled, Change in a Resident ' s Page 1 of 2 056136 056136 10/19/2023 Villa Mesa Care Center 867 E. 11th St Upland, CA 91786

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Condition or Status, dated, May 2017, the P&P indicated, Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc . Policy Interpretation and Implementation . 4. Unless otherwise instructed by the resident, a nurse will notify the resident ' s representative when . d. It is necessary to transfer the resident to a hospital/treatment center.). During a review of the facility ' s policy and procedure (P&P), titled, Charting and Documentation, dated, July 2017, the P&P indicated, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. Policy Interpretation and Implementation . 7. Documentation of procedures and treatments will include care-specific details, including. a. The date and time the procedure/treatment was provided . f. Notification of family physician or other staff, if indicated; and g. The signature and title of the individual documenting. 056136 Page 2 of 2