Health inspection·September 26, 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 needs for two of three sampled residents reviewed (Residents A and B), when: Residents Affected - Few 1. Resident A was not provided bedrails for repositioning as requested. This failure had the potential for Resident A to have unmet needs. 2. Resident B's call light was found not within her reach. This failure had the potential for Resident B not to be able to call for assistance from the staff. Findings: On September 4, 2024, at 8:55 a.m., an unannounced visit to the facility was conducted to investigate an allegation of quality care and treatment issue. 1. A review of Resident A ' s, admission Record, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included Aftercare Following Joint Replacement Surgery. Resident A ' s History and Physical, dated August 14, 2024, indicated Resident A has the capacity to understand and make decision. A review of Resident A ' s Bedrail Assessment, dated August 10, 2024, indicated .Does the resident have bed mobility issue to cognitive losses .Yes .Indication for Use .Bedrail/Transfer bar is indicated for mobility/transfer purposes and resident demonstrates ability to use equipment as an enabler . On September 10, 2024, at 1:49 p.m., during interview, the Director of Nursing (DON) stated if a family member requested for a bedrail, the Registered Nurse Supervisor (RNS) would assess the resident, and after the assessment, she would refer it to the Maintenance Director for installation of the bedrail. On September 11, 2024, at 9:45 a.m., during a concurrent interview and record review of the Maintenance Repair Log from August 9 to August 15, 2024, with the Maintenance Director (MD), the M.D. stated he did not install the bedrail for Resident A since there was no request made by the nurse for bedrail installation for Resident A ' s bed. Page 1 of 2 056185 056185 09/26/2024 Menifee Lakes Post Acute 27600 Encanto Drive Sun City, CA 92586

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On September 13, 2024, at 3:06 p.m., during interview with the DON, the DON stated all beds are without bed rails, and bedrails will be installed if assessed to be beneficial for the resident. A review of the facility policy and procedure titled Proper Use Of Bed Rails, dated December 19, 2022, indicated .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails .Resident Assessment . As part of the resident ' s comprehensive assessment, the following components will be considered when determining the resident ' s needs, and whether or not the use of bed rails meets those needs: Acute medical or surgical interventions . A review of the facility policy and procedure titled Accommodation of Needs, dated December 19, 2022, indicated .The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident . 2. A review of Resident B ' s s admission record, indicated Resident B was admitted to the facility on [DATE], with diagnoses which included dementia (forgetfulness), and legal blindness. On September 4, 2024, at 12:10 p.m., during concurrent observation and interview, Resident B's bed backrest was positioned at 45-degree angle and her call light was clipped on the top portion of her bed, not within her reach. On September 4, 2024, at 12:15 p.m. during a concurrent observation and interview, with the Certified nurse Assistant (CNA), the CNA stated Resident B ' s call light was located at the top part of her bed, far from her reach. The CNA stated the call light should be clipped to her clothes, close to her, for her to be able to ask for help when necessary. A review of Resident B ' s Care Plan, dated July 14, 2024, at indicated .Resident B at risk for fall r/t (related to) non-ambulatory status, legal blindness, dementia .Interventions .Place resident ' s call light within reach . On September 11, 2024, at 3:42 p.m., during interview, the Registered Nurse Supervisor (RNS) stated the expectation for the staff was to place the call light within reach of the resident at all times. A review of the facility policy and procedure titled Call Lights: Accessibility and Timely Response, dated December 19, 2022, indicated, .Staff will ensure the call light is within reach of resident and secured, as needed . 056185 Page 2 of 2