Health inspection·October 23, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for one of two sampled residents (Residents 1). Residents Affected - Few * The facility failed to ensure Resident 1 was provided with assistance in a timely manner. This failure had the potential to negatively impact the residents' physical and psychosocial well-being. Findings: Medical record review for Resident 1 was initiated on 10/23/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical Examination dated 10/11/23, showed Resident 1 did not have the capacity to understand and make decisions, and was diagnosed with left ICH and right hemiplegia. Review of Resident 1's care plan dated 10/11/23, showed a care plan problem addressing Resident 1's risk for falls related to recent hospitalization, intracranial hemorrhage, and dementia. The care plan interventions included to anticipate and meet the needs, ensure the call light within reach, and encourage to use the call light for assistance as needed. Review of Resident 1's Change of Condition dated 10/13/23 at 0817 hours, showed the family member (caregiver) reported Resident 1 was on the floor. Review of Resident 1's progress note dated 10/13/23 at 0849 hours, showed at 0530 hours, the caregiver reported Resident 1 found on the floor on the right of his bed leaning on his right arm and slowly laid his head on the floor. The caregiver stated Resident 1's legs were slipping out of bed. The caregiver put Resident 1's legs back on the bed. Resident 1 slowly slipped off again and slid his body down from the bed to sit on the floor. Review of the Nurse Call Activities Report dated 10/26/23 at 1018 hours, showed Room A had a call started on 10/13/23 at 0531 hours and ended at 0545 hours. The call duration was 13:56 minutes long. On 10/23/23 at 1020 hours, a telephone interview was conducted with CNA 1. CNA 1 stated around 0400 hours, CNA 1 saw Resident 1 sleeping when she passed by his room. Resident 1's caregiver was sitting on the left side of his bed. Later, CNA 1 was called to Resident 1's room and found Resident 1 was on the floor on the right side of his bed. CNA 1 stated she did not hear the call light when working in other room. CNA 1 stated Resident 1 was moving a lot, moved to the right side, and tried to get (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: 055237 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 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 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)