Health inspection·March 11, 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 one of three residents (Resident 2) call light remained within reach and accessible for a distressed resident (Resident 2) while in bed. Residents Affected - Few This failure resulted in Resident 2 ' s needs not being met in a timely manner and deprived this mentally compromised resident of assistance when needed. Findings: During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 2 was initially admitted on [DATE], with diagnoses which included: Anxiety, Depressive disorder, schizoaffective disorder (mental illness that can affect your thoughts, mood, and behavior) and palliative care (relieving the symptoms of an incurable medical condition using comfort measures). During a concurrent observation and interview with Resident 2, on February 15, 2024, at 12:07 PM, Resident 2 is observed shaking, crying, and wearing a sweatshirt with sweatpants. Resident 2 states, I need to get undressed. I have on my hot clothes. Come here. Resident 2 stated further, My nurse (certified nursing assistant, cna 2) just pushed my table in front of me and left. I can ' t reach my call light. I don ' t know where it is. (Cna 2) did not give me my call light. Can you tell someone to help me? Resident 2 did not locate her call light to call for assistance. During a concurrent observation and interview with a Certified Nursing Assistant (Cna 1) in Resident 2 ' s room, on February 15, 2024, at 12:13 PM, Cna 1 verified the call lights location, on the floor, close to the wall, near the head of the bed. Cna 1 stated, The call light is supposed to be in reach. The call light is not within reach and Resident 2 is not able to use the call light. (Cna 2) was just in here with Resident 2. Cna 1 stated further Resident 2 had a panic attack (sudden episode of intense fear that triggers severe physical reactions). During an interview with Licensed Vocational Nurse (LVN 1), on February 15, 2024, at 12:33 PM, We are to make sure the call lights are in reach, and the residents can use the call light if they need something. It ' s for their safety and to meet their needs. Room rounds are made often to make sure the call lights are in place. Resident 2 gets very anxious and has panic attacks. LVN 1 stated further, Resident 2 ' s call light should have been within reach. During an interview with Director of Nursing (DON), on February 15, 2024, at 2:40 PM, DON stated, The call lights are to be within reach to attend to the resident ' s needs. DON stated further Resident 2 ' s call light should have been within reach. Page 1 of 2 055557 055557 03/11/2024 Creekside Post Acute 35253 Avenue H Yucaipa, CA 92399

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the clinical record for Resident 2, the history and physical, dated January 22, 2023, indicated Resident 2 can make her own decisions. During a review of Resident 2 ' s clinical record, Resident 2 ' s care plans indicated: 1.Dated September 9, 2023, Resident 2 has an activity of daily living self-care performance deficit related to activity intolerance, confusion, disease process, impaired balance, limited mobility, pain, and shortness of breath with interventions including: Encourage the resident to use bell to call for assistance. 2.Dated September 9, 2023, Resident 2 has a communication problem related to impaired cognition (think, explore. figure things out), and depression with interventions including Ensure/provide a safe environment. Call light in reach. The facility policy and procedure titled, Answering the Call Light dated September 2022, indicated The purpose of this procedure is to ensure timely responses to the resident ' s requests and needs .5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor . 055557 Page 2 of 2