Health inspection·September 20, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor resident rights when: Residents Affected - Few A hot shower request for three of nine sampled residents (Resident 1, 2 and 6), was not an option, and the alternative was a cold shower or no shower. This failure resulted in Resident 1, 2 and 6 individual preferences or choice being devalued (reduce or underestimate the worth of importance of) and not being treated with honor or respect. Findings: During an interview on 9/19/24 at 6:35 p.m., with Resident 1, Resident 1 stated the facility did not have hot water in the showers and she was not able to take a shower as scheduled. Resident 1 stated the facility has two showers but one had been broken for some, the facility only had one working shower and now that shower wasn ' t working. Resident 1 stated she cannot shower tonight (9/19/24) unless she wanted a cold shower. During an observation on 9/19/24 at 6:40 p.m., the [NAME] side shower was turned on. Water was turned on for 4 minutes and no hot or warm water came out of shower head faucet. During a concurrent observation and interview on 9/19/24 at 6:44 p.m. with Certified Nursing Assistant (CNA) 2 in the [NAME] side shower room. CNA 2 touched the water coming out of the shower head and stated they have not had hot water today (9/19/24). CNA 2 stated some residents did not want to shower in cold water. CNA 2 stated residents could get bed baths, but it would be cold water. During an interview on 9/19/24 at 6:47 p.m., with Assistant Administrator (ADMA) the ADMA stated she was not aware of the facility not having hot water toady (9/19/24). During an interview on 9/19/24 at 7:15 p.m., with Licensed Vocation Nurse (LVN 2), LVN 2 stated she did not know there was no hot water in the shower room today (9/19/24). LVN 2 stated staff had not reported to her that there was no hot water for showers. During an interview on 9/19/24 at 7:20 p.m., with Housekeeper ([NAME]), in the [NAME] side shower room, [NAME] stated the Maintenance Director (MAINT) knew there was no hot water for showers today (9/19/24). [NAME] stated she attempted to call the maintenance director at 7:21 p.m. to discuss when Page 1 of 3 555892 555892 09/20/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0550 the hot water would be working but there was no answer. Level of Harm - Minimal harm or potential for actual harm During an interview on 9/19/23 at 7:24 p.m., with Resident 6, Resident 6 stated hot water has been out for some time now. Resident 6 stated he takes showers in cold water because he doesn ' t want to be stinky. Resident 6 stated he doesn ' t like taking cold showers, but he does, because he wants to make sure he doesn ' t stink. Resident 6 stated he let the maintenance know there was no hot water, and it has been out for weeks. Residents Affected - Few During an interview on 9/19/24, at 7:47 p.m., with Director of Nurses (DON), the DON stated she just found out that the facility did not have hot water for showers today (9/19/24). During an interview on 9/19/24 at 7:55 p.m., the Administrator (ADM), the ADM stated MAINT is new to the facility and didn ' t let her know there was no hot water today (9/19/24). ADM stated it is the expectation that MAIN notifies me or the DON. During an interview on 9/20/24 at 10:40 a.m., with the DON, the DON stated MAINT was aware there was no hot water the morning of 9/19/24. The DON stated MAINT did not communicate per the facility ' s Emergency policy and procedure. ADM stated her expectation is notification will be provided to ADM and immediate interventions should put in place, a all hands should be on deck to resolve an issue of no hot water. DON stated not following P&Ps could have caused hygiene issues and could potentially lead to skin breakdown for residents. During an interview on 9/20/24 at 11:39 a.m., with MAINT, MAINT stated he was aware there was no hot water in the [NAME] wing shower room at 11 a.m. on 9/19/24. MAINT stated he called a plumber, and they were onsite at 3:12 p.m. to check why there was no hot water. MAINT stated he did not notify anyone that there was no hot water for resident baths because everybody was busy. MAINT stated he did not follow the appropriate steps and let the facility leadership know there was no hot water. MAINT stated because there was no hot water, residents were not able to take hot showers. During an interview on 9/20/24 at 12:30 p.m., with Resident 2, Resident 2 stated he didn ' t get a shower yesterday (9/19/24) because the water was freezing. Resident 2 stated he told the staff there was no hot water, but they don ' t care about us. During an interview on 9/20/24 at 1:15 p.m., with the DON, DON stated she was aware of the hot water issue when ADMA informed her the evening of 9/19/24. The DON stated when there is no hot water for residents the potential problems could include infection control from not showering the residents and residents could be upset because they cannot shower. During an interview on 9/24/24 at 2:55 p.m., with the ADM, ADM stated resident ' s rights were not honored, if they wanted a hot shower, they should be able to take one. ADM stated residents can feel disrespected because a hot shower is not available to them. During a review of the policy and procedure titled, Resident Rights, dated Jan. 2024, indicated, .The facility must fully inform residents of services available in the facility and or related changes .Resident have a right to be free of interference, coercion, discrimination and reprisal in exercising his/her rights .The resident has a right to be treated with respect and dignity .Has the right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and support for daily living safely . 555892 Page 2 of 3 555892 09/20/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the job description title, Plan Operations Manager dated 2023, indicated .Reports observations concerning structural, equipment and furniture defects and malfunctioning to appropriate personnel . Follows established safety policies and procedures . identified and corrects safety hazards, reports safety concerns as required . During a review of the Emergency Operations Program and Plan Manual titled, Communication Plan (undated), indicated, .Communication plan support rapid and accurate communication both internally and externally .information may be used .to notify staff of an emergency that may impact or involve them . first person to recognize the incident will immediately notify their supervisor . 555892 Page 3 of 3