Health inspection·April 3, 2025

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide the necessary care and services to ensure residents received care and services with activities of daily living (ADL) when two out of three residents (Resident 1 and Resident 2) waited a long time to be cleaned and changed. Residents Affected - Few This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) ' s health and safety at risk, when the residents ' activities of daily living were not met in timely manner. Findings: 1. During review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a condition when the lungs cannot get enough oxygen into the blood or get rid of the waste product from the blood), morbid obesity (a condition with too much body fat), dependence on respirator (a condition when one cannot breath on their own and needs a machine) , and quadriplegia (a condition in which all four limbs are paralyzed). During an observation and interview on April 3, 2025, at 6:10 AM with Resident 1, Resident 1 stated, I had to wait a long time to be changed a couple of times, and I understand that I am not the only that needs help, but you don ' t get the help quickly. During a review of the clinical record for Resident 1, the Care Plan Report dated October 20, 2024, indicated, Focus: Resident has problems with ADL decline . related to muscle wasting and atrophy. Goal: Resident will improve ADL performance on grooming, upper body dressing lower body dressing toileting . 2. During review of Residents 2 ' s admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included Chronic respiratory failure, chronic obstructive pulmonary disease (a condition that makes it harder to breath), paraplegia (a condition that the legs and not able to that part of the body) and dependence on respirator. During an observation and interview on April 3, 2025, at 6:15 AM, with Resident 2, Resident 2 stated, It is bad on the night. Sometimes I wait a while before I get help with a change. During a review of the clinical record for Resident 2, the Care Plan Report dated January 29, 2025, indicated, Focus: [name of Resident 2], has an ADL self-care performance deficit related to disease Page 1 of 2 555379 555379 04/03/2025 Asistencia Villa Healthcare Center 1875 Barton Rd Redlands, CA 92373

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few process paraplegia unspecified. Goal: [name of Resident 1] will maintain current level of function . Intervention: . The resident total dependent on 1 staff with personal hygiene and oral care. During an interview with Certified Nursing Assistant (CNA 2), on April 3, 2025, at 6:30 AM, CNA 2 stated, I am able to provide care to the residents but sometimes it takes a while to attend to a resident need when there is not enough help. During an interview with Director of Nursing (DON), on April 3, 2025, at 7:35 AM, DON stated, I expect nursing staff to attend to residents and provide assistance in a timely manner. During a concurrent interview and review on April 15, 2025, at 3:09 PM with DON, facility ' s policy and procedure (P&P), titled, Activities of Daily Living (ADLs), Supporting, dated March 2018 was reviewed. The P&P indicated, . 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical conditions(s) demonstrate that diminishing ADLs are unavoidable . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care . DON stated, Residents needs should have been met in a timely manner. 555379 Page 2 of 2