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 (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: 555379 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 555379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asistencia Villa Healthcare Center 1875 Barton Rd Redlands, CA 92373 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)