Health inspection·March 1, 2023

§483.10(e)(3) Resident Rights The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. 22 CCR §72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. 22 CCR §72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. The facility failed to ensure the reasonable accommodation of needs of each resident were met for Resident 1, Resident 2, Resident 4 and Resident 11. The facility failed to respond timely to the call lights when the four residents needed assistance. As a result, on 1/20/2023, Resident 1 stated feeling helpless. In addition, Resident 2, Resident 4, and Resident 11 stated feeling frustrated which could affect Resident 1, 2, 4 and Resident 11’s mental and psychosocial well-being. a. A review of the Admission Record indicated the facility admitted Resident 11 on 8/4/2022 with diagnoses including multiple sclerosis (a condition that can affect the brain and spinal cord causing a wide range of potential symptoms including problems with vision, arm or leg movement, sensation, or balance) and hypertension (high blood pressure). A review of the MDS dated 8/9/2022 indicated Resident 11 was alert to year, month, and day. Resident 11 needed set up help when eating and needed one- person physical assistance with bathing. Resident 11 needed two or more persons physical assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of the Care Plan initiated on 8/24/2022, indicated Resident 11 was incontinent of bowel and bladder and is at risk for skin breakdown. The care plan goal included resident will have incontinence care needs met by staff to maintain dignity and to prevent incontinent related complications. The care plan interventions included to offer/assist resident with commode as requested/needed and to provide privacy and comfort. During a telephone interview on 10/19/2022, at 11:09 a.m., Resident 11 stated she would use the call light to ask for assistance to be changed or use the commode. Resident 11 stated it takes a long time for the nurses to respond to her request and stated " ...just makes me feel frustrated and angry that it takes awhile to help me." b. A review of the Admission Record indicated Resident 4 was admitted on 10/12/2022, with diagnoses including artificial left knee joint, difficulty walking and muscle weakness. A review of the MDS dated 10/16/2022, indicated Resident 4 was oriented to year and month. Resident 1 needed one-person physical assistance with bed mobility, transfer, walk in the room, eating, personal hygiene, bathing and two or more persons physical assistance with toilet use. During an interview on 10/20/2022, at 10:50 a.m., Resident 4 stated she needed assistance to go to the bathroom because of her knee. Resident 4 stated when she uses the call light it takes awhile before someone will come and assist her. Resident 4 stated, rather than wait, she would go to the bathroom by herself. Resident 4 stated this made her feel frustrated. A review of the Resident Council Minutes for the months of 6/2022, 7/2022 and 8/2022 were reviewed with the activity assistant (AA). The Resident Council Minutes indicated the staff response to call lights were the following: -6/23/2022, of the 39 residents that were interviewed, 12 residents indicated the waiting time was too long, slow response of call light at night and turned off the call light but never came back. -7/28/2022, of the 48 residents that were interviewed, 11 residents indicated the waiting time was too long, slow response of call light at night and turned off the light but never came back. -8/23/2022, of the 52 residents that were interviewed, 10 residents indicated the waiting time was too long, slow response of call light at night and turned off the light but never came back. During a concurrent interview on 10/20/2022, at 12:56 p.m., the AA stated if the call lights were not answered timely, residents can become frustrated and become angry. During an interview on 10/20/2022, at 1:14 p.m. the Director of Staff Development (DSD) stated residents used the call lights because they need assistance such as going to the bathroom or brushing their teeth. The DSD stated staff were given reminders to answer the call lights timely but continue to have the problems of not responding to call lights timely. During an interview on 11/2/2022, at 1:19 p.m., the Director of Nursing (DON) stated it was the responsibility of all staff to respond to the call lights timely. c.A review of the Admission Record indicated the facility admitted Resident 1 on 12/22/22 with diagnoses including right artificial knee joint and muscle weakness. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 12/27/22 indicated Resident 1 was alert to year, month, and day. Resident 1 needed one-person physical assistance with activities of daily living (ADLs, including bed mobility, transfers, eating). A review of the Admission Record indicated the facility admitted Resident 2 on 12/13/2022 with diagnoses including joint replacement surgery and difficulty in walking. Resident 2 needed one-person physical assistance with ADLs. A review of the Resident Council Minutes dated 11/29/2022 indicated 14 residents complained that when they used the call light, the waiting time was too long, slow response of call light at night and staff turned off the call light, but never came back. A review of the Resident Council Minutes dated 12/29/2022 indicated five residents complained that the waiting time for staff response to call lights was too long. The council minutes indicated Resident 2 complained that she waited two hours before a staff responded to her. During an interview on 1/11/2023 at 2:41 p.m., Resident 2 stated she would use the call light and it takes 20 minutes for a staff member to come for her assistance or no one comes at all. Resident 2 stated this made her feel frustrated. During a telephone interview on 1/20/2023 at 3:50 p.m., Resident 1 stated she would use the call light to ask for assistance and no nurse would come for her assistance. Resident 1 stated this made her feel helpless. During an interview on 1/25/2023 at 1:48 p.m., the registered nurse supervisor (RNS 1) stated call lights were everybody ' s business. Everyone must respond to the call lights, if the direct staff was not available anyone can respond to the call light. During an interview on 1/25/2023 at 2:40 p.m., DON 1 stated staff should respond to calls lights as soon as possible. A review of the facility policy titled, "Answering Call Lights," revised on 3/2021 indicated the purpose of the policy was to ensure timely responses to the resident’s requests and needs. The policy indicated when answering from the call light station, turn off the signal light. Identify yourself and politely respond to the resident by his/her name. If a resident needs assistance, indicate the approximate time it will take to respond. If the resident’s request requires another staff member, notify the individual. If the resident’s request was something you can fulfill, complete the task within five minutes if possible. If uncertain as to whether a request can be fulfilled or if you cannot fulfill the resident ' s request, ask the supervisor for assistance. The facility failed to ensure the reasonable accommodation of needs of each resident were met for Resident 1, Resident 2, Resident 4 and Resident 11. The facility failed to respond timely to the call lights when the four residents needed assistance. As a result, on 1/20/2023, Resident 1 stated feeling helpless. In addition, Resident 2, Resident 4, and Resident 11 stated feeling frustrated which could affect Resident 1, 2, 4 and Resident 11’s mental and psychosocial well-being. The above violation had a direct or immediate relationship to the health, safety, and security of Resident 1, Resident 2, Resident 4 and Resident 11.