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 Page 1 of 2 055237 055237 10/23/2023 Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627

F 0558 up from the right side of his bed. Level of Harm - Minimal harm or potential for actual harm On 10/23/23 at 1100 hours, a telephone interview was conducted withthe caregiver. The caregiver stated Resident 1 had been restless the whole night and getting out of bed. Every time, Resident 1 put his legs out of bed, the caregiver put him back to bed. The caregiver stated Resident 1 kept getting out of bed and she could not control Resident 1, then she pressed the call light to get assistance from the nurses. No one responded for 20 minutes. The caregiver stated when Resident 1 slid out of bed, she helped him slide to the floor and lay down on the floor. The caregiver then walked to the nurses' station to get help. The caregiver stated Resident 1 wanted to get up. The resident asked why he could not get up and stated he just wanted to stand up and go home. The caregiver stated Resident 1 could not sit up in chair with one side weakness and was too heavy to be transferred by one person assistance. Residents Affected - Few On 10/23/23 at 1130 hours, a telephone interview was conducted withLVN 1. LVN 1 stated during her rounding, Resident 1 was calm, quiet, and confused. Resident 1 was thrashing his leg off the bed but still in bed. LVN 1 stated around 0530 hours, when LVN 1 was in the hallway, the caregiver came out from Resident 1's room and told her that Resident 1 was on the floor. Resident 1's call light was on. LVN 1 came to the room and found Resident 1 was leaning on his arm, sitting on the floor with his head up; and Resident 1 put his head down when LVN 1 called for more help. Resident 1 fell on the right side of his bed and the caregiver was sitting on the left side of the bed. LVN 1 was asked if she saw the call light, LVN 1 stated she came out from the other resident's room when the caregiver approached her, and she did not know how long the caregiver had called. On 10/26/23 at 0925 hours, a telephone interview was conducted with RN 1. RN 1 stated the call light should be answered as soon as possible, in about one to two minutes, even at night. The nurse could see the call light ringing at the call light panel in the nurses' station. 055237 Page 2 of 2