Health inspection·October 19, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 ensure resident needs were met when: Residents Affected - Some 1. Staff did not respond in a timely manner to calls for help for 5 of 13 sampled residents (Resident 2, Resident 3, Resident 5, Resident 7, and Resident 13); and, 2. The nursing call light system was not fully functional for rooms 28-53 (South Hall) and 45 of 47 residents were not provided an alternate audible method to call staff for help. These failures resulted in Resident 7 not receiving the assistance needed after she fell on 9/2/23 and 9/5/23, and Resident 2, Resident 3, Resident 5, and Resident 13 waiting up to three hours for assistance, with a potential to experience anxiety and feelings of neglect. Findings: 1a. A review of Resident 7's admission Record indicated Resident 7 was admitted to the facility with diagnoses which included a fracture of her right lower leg and unsteadiness on her feet. During an interview with Family Member (FM) 2, on 9/26/23, at 8:28 AM, FM 2 stated Resident 13 called her around 7 PM or 7:15 PM on 9/2/23, because her roommate, Resident 7, had fallen. FM 2 stated Resident 13 pressed her call light, and no one came. FM 2 explained she could hear yelling and screaming over the phone. FM 2 stated she then called the facility, but no one answered the phone, and she decided to call the police department to do a welfare check for Resident 7. A review of the police department (PD) document titled, Police Event Information, dated 9/2/23, indicated the call from FM 2 was initiated at 7:45 PM, with dispatch receiving the information at 7:47 PM, and the call being dispatched at 7:49 PM indicating, 2ND HAND INFO FROM [Resident 13] WHOM IS A RESIDENT .ROOMMATE FELL WHEN TRYING TO USE THE BATHROOM -- SHE HAS BEEN SCREAMING FOR HELP FROM THE NURSE AND NOBODY IS COMING -- RP [FM 2]TRIED TO CALL NUMBERS SHE HAS FOR FACILITY AND NOBODY ANSWERED . The PD record indicated two attempts were made to reach the facility by phone. A review of Resident 7's clinical document titled, Progress Notes, dated 9/2/23 at 8:59 PM, indicated, Resident called the police and informed them she had fall [sic] and nobody came for [sic] help . During a telephone interview with the Police Department Representative (PD Rep), on 9/26/23, at 8:45 AM, the PD Rep confirmed they received a call to do a welfare check at the facility, on 9/2/23, at 7:47 PM, stating the call was made for Resident 13 regarding Resident 7. Page 1 of 4 555245 555245 10/19/2023 North Park Post-Acute 2586 Buthmann Ave Tracy, CA 95376

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A voicemail left by Police Officer (PO) 1, on 9/26/23, at 2:56 PM, indicated, .[FM 2] called in about another resident [Resident 7] who had fallen. When we arrived on scene she was already in bed and was okay. She advised she had fallen a while prior to our arrival but that it was an accident, and she was able to pick herself up after some time. She advised she did urinate on herself, so nurses were advised. Nurses were confused when I arrived looking for the patient to see if she was still on the floor. They didn't know she had fallen or anything like that . During an interview with PO 1, on 9/26/23, at 5:42 PM, PO 1 stated prior to arriving at the facility they tried to call the facility twice and no one answered the phone. During a telephone interview with Licensed Nurse (LN) 7, on 10/19/23, at 11:26 AM, LN 7 stated she remembered the fall Resident 7 had on 9/2/23. LN 7 further stated the police came around 8 PM stating Resident 7's roommate had called 911. LN 7 explained it was after the police arrived that she learned about Resident 7's fall. b. During an interview with FM 1 on 9/26/23, at 8:15 AM, FM 1 stated Resident 13 (Resident 7's roommate) called around 2 AM on 9/5/23. FM 1 stated Resident 13 was distraught, stating she had been trying to get staff members' attention and had been pressing her call light and no one answered. FM 1 stated after he got off the phone with his family member, he tried calling the facility and no one answered. FM 1 explained Resident 13 called him later crying, stating her roommate had passed away. During a telephone interview with Certified Nursing Assistant (CNA) 4, on 9/27/23, at 3:40 AM, CNA 4 stated she assisted another CNA to place Resident 7 back into bed after she had fallen and passed away. CNA 4 stated it was around 2:50 AM. During a telephone interview with LN 4, on 9/27/23, at 4:33 AM, LN 4 stated Resident 7 was found on the floor unresponsive and 911 was called at 2:54 AM, the police were called at 3:04 AM. During an interview with CNA 8, on 9/27/23, at 12:05 PM, CNA 8 stated on the morning of 9/5/23 at 2:30 AM she returned from her lunch break and saw two call lights on for room [ROOM NUMBER] and room [ROOM NUMBER]. CNA 8 stated she went to room [ROOM NUMBER] first. CNA 8 explained when she went to room [ROOM NUMBER], Resident 13's call light was on. CNA 8 further explained she saw Resident 7 laying on the floor and ran out to get the nurse, stating LN 4 was in the hallway. CNA 8 stated she called other nurses from other stations and the nurses checked on Resident 7, and one of them called 911. 1c. During an interview with Resident 2 in the South Hall, on 9/26/23, at 9:41 AM, Resident 2 stated staff did not always answer the call light. Resident 2 explained the longest she has had to wait for staff to answer her call light was 1 hour and 45 minutes, stating that she timed it. During an interview with Resident 3 in the South Hall, on 9/26/23, at 9:50 AM, Resident 3 stated it took a very long time for staff to answer the call light. Resident 3 stated the night shift was the worst, taking 30-90 minutes to answer the call light. Resident 3 further explained he was concerned about how long it took staff to respond to his call light, and stated, .It makes me nervous that they take so long .they wouldn't get here in time to have any effect on an event like a heart attack . During an interview with Resident 5 in the South Hall, on 9/26/23, at 10 AM, Resident 5 stated it has taken up to 3 hours for call lights to be responded to. 555245 Page 2 of 4 555245 10/19/2023 North Park Post-Acute 2586 Buthmann Ave Tracy, CA 95376

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility policy titled, CALL LIGHT ANSWERING, revised 8/12/21, indicated, .It is the policy of this facility to provide the resident a means of communication nursing staff as indicated .Answer the call light/bell within a reasonable time .Acknowledge the resident's call light/bell .The nursing staff will ensure that the resident's call for assistance is acknowledged . 2. During an observation at the South Hall Nursing Station, on 9/26/23, at 3:15 AM, the Nursing Call Light System panel had lights displaying, but was not making an audible tone. Upon further observation, the system was set to low tone. There was still no audible tone when switched to Hi tone. During an interview with Licensed Nurse (LN) 2, on 9/26/23, at 3:30 AM, LN 2 stated the call light system in the South Nursing Station broke a while ago. LN 2 explained the call system in the South Nursing Station had not been working since January or February 2023. During an interview with LN 1 on 9/26/23, at 3:32 AM, LN 1 stated the importance of the call light system working was so she could hear the tone and see where the light was, so she could go attend to it in time. LN 1 further explained a functioning call light system was so that residents would have their needs met. During an interview with LN 3, on 9/26/23, at 4:10 AM, LN 3 stated if the audible tone of the call light system is not working, residents should have a bell to ring and explained the facility had bells. During an interview with LN 1, on 9/26/23, at 4:30 AM, LN 1 confirmed there was no audible tone at the South Hall Nurses Station when the call lights were pressed in rooms 36 through 53. During an interview with Resident 1who resided in the South Hall on 9/26/23, at 4:38 AM, Resident 1 stated she was given a bell to ring in case she was choking, and no one was coming when she pressed her call light. During an interview with the Director of Nursing (DON) on 9/26/23, at 6:50 AM, the DON stated there should have been sound for the call lights, and further stated she was not sure how long they had not been working. The DON confirmed there was no sound when she pressed a call light in room [ROOM NUMBER] either at the room or at the nurse's station. The DON stated the importance of the Nurse Call Light System was so staff were aware of residents needing assistance. The DON explained if the sound was not working residents should be supplied with manual bells to ring. During a concurrent observation and interview with the Maintenance Director (MNT Dir), on 9/27/23, at 11:25 AM, the MNT Dir and The Department tested every call light from room [ROOM NUMBER]-53. The MNT Dir confirmed there was no audible sound from the call lights and no sound at the South Hall Nurses Station for rooms 28-53. During an interview with LN 5 on 9/27/23, at 11:57 AM, LN 5 stated the call lights had not made sounds since she started working at the facility in July 2023. During an interview with CNA 7, on 9/27/23, at 12 PM, CNA 7 stated in the year she had worked at the facility the sound has never worked at the South Nurses Station. During an interview with LN 6, on 9/27/23, at 12:02 PM, LN 6 stated it had been over 6 months since the sound for the call lights in the South Nursing had worked. 555245 Page 3 of 4 555245 10/19/2023 North Park Post-Acute 2586 Buthmann Ave Tracy, CA 95376

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview with the DON, on 9/27/23, at 2:20 PM, the DON stated the residents should have a bell if the sound was not working on the call light system. The DON confirmed 2 of the 47 residents in the South Hall had bells on 9/26/23. Residents Affected - Some 555245 Page 4 of 4