Health inspection·December 27, 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 accommodate one (1) of two (2) sampled residents (Resident 1) by failing to ensure the residents call light (device used by residents to call staff) was within reach. Residents Affected - Few This deficient practice has the potential to delay in the necessary care and services and/or needs not being met. Findings: During a review of Resident 1's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of muscle weakness, difficulty in walking, alzheimer's disease (a disease characterized by a progressive decline in mental abilities), depression (elevation or lowering of a person's mood) and anxiety (intensive, excessive, and persistent worry and fear about everyday situations). During a review of Resident 1's History and Physical (H&P), dated 10/11/2024, indicated resident has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/11/2024, indicated resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, lower body dressing, putting on/taking off footwear. The MDS also indicated Resident 1 also required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and upper body dressing. During a review of Resident 1's care plan with focus Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person's performs daily)/ self-care, revised 9/18/2024, indicated call light within reach and to assist with ADLs as needed. During a review of Resident 1's care plan with focus on fracture, dated 12/21/2024, indicated call light close and answered promptly. During a review of Resident 1's care plan with focus on actual fall, dated 12/21/2024, indicated call light within reach and answer promptly. During a review of Resident 1's care plan with focus risk for falls, revised 12/26/2024, indicated Page 1 of 2 055548 055548 12/27/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0558 call light within reach and answer promptly. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview in Resident 1's room on 12/27/2024 at 9:35 AM, Resident 1's call light was placed above Resident 1's shoulder between the pillow and side rail and Resident 1 was observed trying to reach for the call light but was unable to. Resident 1 stated if she has the call light than she can use it to the call the facility staff for assistance, but she just gives up because she cannot reach her call light. Residents Affected - Few During a concurrent observation in Resident 1's room and interview on 12/27/2024 at 9:59 AM, Registered Nurse 1 (RN 1) stated the call light was not within Resident 1's reach and that is not okay because the resident needs the call light to ask for assistance when needed. During an interview on 12/27/2024 at 12:09 PM, the Director of Nursing (DON) stated the call light should be within reach of the resident, so the residents can call the nurses when in need of assistance. The DON added if call light is not within the resident's reach and resident was unable to use it to call for staff for help, it will delay meeting the resident's needs and care. During a review of the facility's Policy and Procedure (P&P) titled Call light Communication, revised 1/1/2012, indicated call cords (call lights) will be placed within the resident's reach in the resident's room. The P&P also indicated the facility will provide a call system (included call lights) to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. 055548 Page 2 of 2