Health inspection·June 18, 2024

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 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 call lights were not answered promptly to assist with their activities of daily living. 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 that included chronic obstructive pulmonary disease (COPD - is a common lung disease causing restricted airflow and breathing problems). During a review of the clinical record for Resident 1's the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated March 4, 2024, indicated, Resident 1's score was a 15, which indicated Resident 1 had no mental impairment. In an interview with Resident 1, on June 18, 2024, at 11:15 AM, Resident 1 stated that the average response time for assistance when he uses the call light is 20 minutes. Additionally, Resident 1 mentioned that the staff have at times falsely documented that he refused to shower even though he did not refuse. When questioned about the source of his information, Resident 1 stated that the staff from the previous shift informed him about the false documentation by the previous staff. 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 that included chronic respiratory failure with hypoxia (a condition where a patient does not have enough oxygen [gas essential to living] in the tissues or carbon dioxide [respiratory drive in a human body] in the blood which makes it hard to breath). 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 May 14, 2024, indicated, Resident 2's score was a 15, which indicated Resident 1 had no mental impairment. During an interview with Resident 2, on June 18, 2024, at 11:41 AM, Resident 2 stated that response time for staff to answer call lights ranges from 10 minutes to two hours, with daytime response Page 1 of 2 555379 555379 06/18/2024 Asistencia Villa Healthcare Center 1875 Barton Rd Redlands, CA 92373

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few times averaging one hour at nighttime response times averaging two hours. The resident mentioned that he had to wait in soiled diapers for two hours. The most difficult times to get assistance are between 9:00 PM and 6:00 AM, and during shift changes. During an interview with the Certified Nursing Assistant (CNA 1) on June 18, 2024, at 11:34 AM, CNA 1 stated residents have raised concerns about the lack of shower for several days. CNA 1 also confirmed that some residents have gone without showering for multiple days. During a review of the clinical records, the care plans indicated: 1. Resident 1 ' s care plan dated December 21, 2023, indicated Resident 1 has an activity of daily living deficit (tasks of everyday life) related to congestive heart failure (CHF - heart does not pump enough blood), neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), and obesity (excessive fat). Problem: Eating, personal hygiene, bed mobility, dressing, toilet use, bathing. transfer, walk in room, walk in corridor, locomotion on unit, and locomotion off unit. Plan: Have call light within reach and staff to answer promptly. 2. Resident 2's care plan dated February 18, 2024, indicated Resident 2 has an activity of daily living deficit (tasks of everyday life) related to eating, personal hygiene, bed mobility, dressing, toilet use, bathing, transfer, walk in room, walk in corridor, locomotion on unit, and locomotion off unit. During an interview with the assistant director of nursing (ADON) on June 18, 2024, at 12:10 PM, the ADON did not provide any comment regarding my finding that the staff did not answer call lights on time. However, the ADON, did mention that the CNAs will participate in an in-service regarding answering call lights promptly. During a review of the facility's policy and procedure (P&) titled, Answering the call light, revised, October 2010, the P&P indicated The purpose of this procedure is to respond to the residents requests and needs. 555379 Page 2 of 2