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 Based on observation, interview and record review, the facility failed to ensure the call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of three sampled residents (Resident 2). Residents Affected - Few This deficient practice had the potential to delay the provision of care and services for the resident and their needs not being met. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 11/11/2024 with diagnoses that included dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 11/15/2024, the MDS indicated Resident 2's cognition (a mental process of acquitting knowledge and understanding) was severely impaired. During a review of Resident 2's care plan (a written document that summarizes a resident's needs, goals, and care/treatment) titled, Risk for Fall or Physical Injury, dated 11/11/2024, the care plan indicated an intervention to have call light within reach and answer promptly. During an observation on 12/27/2024 at 11:30 a.m., observed Resident 2's call light was not within reach. Observed Resident 2's call light hanging off Resident 2's overhead lamp. During a concurrent observation and interview on 12/27/2024 at 11:42 a.m., with Registered Nurse 1 (RN 1), observed Resident 2 in bed and Resident 2's call light hanging by the overhead lamp. RN 1 stated the call light has to be within reach of the resident so the resident can call anytime he would need something such as going to the toilet or needing to be changed. RN 1 stated that Resident 2 could potentially sustain skin breakdown if he sits soiled for longer than necessary because of the inability to call for help if the call light is not within his reach. RN 1 stated in such condition wherein the call light is unreachable by the resident, it will result to his needs not being attended timely. During a review of the facility's policy and procedure titled, Call Light- Answering, last reviewed on 2/29/2024, the policy indicated that the purpose of this policy is to meet the resident's needs and requests within an appropriate time frame. It is the only mechanism whereby residents are able to alert nursing personnel to their needs. Each resident receives direction upon admission on how to use the call light system and where the call light is positioned at the bedside .reposition call Page 1 of 2 056031 056031 12/27/2024 Sunland Post Acute 8647 Fenwick Street. Sunland, CA 91040

F 0558 light within resident's reach . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056031 Page 2 of 2