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.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
056185
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056185
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Menifee Lakes Post Acute
27600 Encanto Drive
Sun City, CA 92586
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056185
If continuation sheet
Page 2 of 2
