Health inspection·October 1, 2024

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 observation, interview and record review, the facility failed to ensure call lights were placed within residents ' reach for two of six sampled residents, (Resident 3 and Resident 4. Residents Affected - Few This deficient practice could result in residents not able to call nurses for assistance in case of medical emergency (change in medical condition) and when in need of care and assistance. Findings: a) During a concurrent observation and interview on 10/1/2024 at 10:35 a.m. in Resident 3 ' s room, Resident 3 ' s call light was not visible. When curtain was moved call light was observed clipped on the curtain. The Certified Nurse Assistant (CNA) 5 came inside the room and took Resident 3 ' s call light off the curtain. CNA 5 stated the call light should be placed within Resident 3 ' s reach. CNA 5 stated I do not know why the call light was there (clipped in the curtain). During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with a diagnosis including falls (an unintentional event that results in the person coming to rest on the ground), diabetes (DM-high blood sugar), and hypertension (HTN-high blood pressure) During a review of Resident 3 ' s History and Physical (H&P) dated 3/2/2024, the H&P indicated Resident 3 had the mental capacity to understand and make medical decisions. During a review of Resident 3 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 9/4/2024, the MDS indicated Resident 1 had intact cognitive skills (thought process). The MDS indicated Resident 3 required supervision/touching assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During an interview on 10/1/2024 at 11:25 a.m. with Resident 3, Resident 3 stated I had not seen my call light. The nurse just gave it to me. I need something I press the call light. Resident 3 stated I press the call light when I need something from the nurse. If I have a headache, I can call the nurse and the can come and see me. b) During a concurrent observation and interview on 10/1/2024 at 10:45 a.m. Licensed Vocational Nurse (LVN) 1, in Resident 4 ' s room, Resident 4 was on bed, and the call light was observed clipped on the curtain. Resident 4 stated I do not know where my call light is. LVN 1 stated I do not know Page 1 of 2 055519 055519 10/01/2024 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few why the call light was clipped on the curtain. LVN 1 stated all call lights should be placed within Resident 4 ' s reach. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and re admitted on [DATE], with a diagnosis that included falls, difficult walking (abnormal gait), and HTN. During a review of Resident 4 ' s H&P dated 5/5/2024, the H&P indicated Resident 4 had the mental capacity to understand and make medical decisions. During a review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 1 had intact cognitive skills. The MDS indicated Resident 4 required set-up/ cleaning assistance with ADLs such as dressing, toilet use, personal hygiene, and transfer. During an interview on 10/1/2024 at 11;40 a.m. with Resident 4, Resident 4 stated when I need something, I go and tell the nurses. Resident 4 stated I do not know where the call light is, so I just go and ask them. Resident 4 stated I did not put the light on the curtain. Resident 4 stated sometimes I have the call light with me but sometimes I just put it on the side. Resident 4 stated I do not used the call lights too much, because I cannot find it. During an interview on 10/1/2024 at 12:20 p.m. with the CNA 5, CNA 5 stated all call lights must place within residents ' reach. Residents 3 and 4 should be able to call the nurse in cases of emergency. CNA 5 stated call lights should not be clipped on the curtain. During a review of the facility ' s policy and procedures (P&P) titled, Call Light, dated, 1/27/2021 the P&P indicated call device should be placed within resident ' s reach before leaving the room. 055519 Page 2 of 2