Health inspection·April 30, 2025

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 its Activities of Daily Living ADLs policy and procedure for 3 of 3 sampled Residents (Resident ' s 1,2 and 3) when: Resident ' s 1, 2 and 3 were left soiled and wet on observation April 30, 2025. Residents Affected - Few This failure had the potential to cause (Resident 1,2, and 3) health and safety to be at risk for skin breakdown when their care needs were not met. Findings: 1. During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: encephalopathy (brain disease altering function, causes: infection tumor or stroke), respiratory failure, tracheostomy status (trach tube assisting with breathing). Hypertension (high blood pressure). During a concurrent observation and interview on April 30, 2025, at 11:30AM, with License Vocational Nurse (LVN1) at bedside assisting during observation. Resident 1 brief is completely drenching wet, linen sheet wet, gown wet. LVN1 states, the Certified Nursing Assistant (CNA) is at lunch right now, he last changed, around 8AM he had Bowel Movement. I agree he is completely soiled wet, he should not be like this, the CNA is at lunch. During an interview on April 30, 2025, at 12:52 PM with the Certified Nursing Assistant (CNA1), CNA1 states, I check on the residents every 1-2 hours. I don ' t know when Resident 1 was last changed, he is not my patient, I was told to clean him up. His brief was really wet. He should not have been left to much time. We know our patients, which one we have to check on frequently and change frequently. I have 12 residents ' assign; I am able to care for all the residents. During a concurrent observation and interview on April 30, 2025, with Director of Nursing (DON), DON viewed the condition I found Resident 1, and informed Resident 2 is also completely soiled wet, briefs soiled wet. DON confirms the status of both residents, and calls for staff to clean both residents up now. 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 to include: metabolic encephalopathy (brain disease caused by body chemical process), chronic respiratory failure, type 2 diabetes (condition affecting how body processes sugar), hypertension (high blood pressure), cerebral infarction (stroke, blood clot in brain). Page 1 of 2 555435 555435 04/30/2025 The Canyons Post-Acute 1350 Reche Canyon Rd Colton, CA 92324

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on April 30, 2025, at 11:39AM, with License Vocational Nurse (LVN1) at bedside assisting during observation. Resident 2 brief drenched wet; gown wet. LVN1 confirms observation, same and Resident 1, can agree this resident should not be left soiled like this. 3. During review of Residents 3s admission Record (general demographics), the document indicated Resident 3 was admitted to the facility on [DATE], with diagnoses to include: cerebral infarction (stroke, blood clot in brain), acute respiratory failure, type 2 diabetes (condition affecting how body processes sugar). During a concurrent observation and interview on April 30, 2025, at 12:36PM, with CAN 2, CAN 2 states, Resident 1 and 2, I changed around 8:30-9:00AM. I checked on both at 10:30AM, got repositioned. Both are heavy wetter ' s, void a lot. I change as they void. They were both dry then I went to lunch. He got cleaned up by the CNA. Observation of Resident 3 with CNA2 at bedside, noted brief wet, moderate amount. CNA 2 states, I will change him now. During an interview on April 30, 2025, with the DON, DON states, The residents has to be dry and repositioned. The residents should not have been left soiled. The charge nurse should be checking on the residents. In Subacute there is a shower team to help the staff in AM and PM shifts, so the CNAs are not showering their residents. There is enough staff to care for the residents. During a review of the facility ' s policy and procedure titled, Activities of Daily Living (ADLs), Supportingrevised [March 2018], the policy and procedure indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 555435 Page 2 of 2