Health inspection·December 12, 2024

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #24) of 1 sampled resident reviewed for vision/hearing was provided their hearing aid when they were received in the facility. Residents Affected - Few Findings included: An undated facility policy titled, Hearing and Vision Services, indicated, 3. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources, for the provision of the vision and hearing services the resident needs. An admission Record revealed the facility admitted Resident #24 on 02/21/200605/13/2024. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease with acute exacerbation. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. According to the MDS, Resident #24 had minimal difficulty with hearing and a hearing aid or other hearing appliance was not used. Resident #24's Order Summary Report which contained active orders as of 12/11/2024, revealed an order dated 05/13/2024, for an audiology consultation and follow-up treatment annually and as needed. Resident #24's audiogram (a graph that visually represented the results of a hearing test) dated 06/11/2024, revealed the resident had hearing loss significant enough to qualify for hearing aids and the provider would start the process of obtaining the resident's hearing aids. Resident #24's consultation report dated 08/20/2024, indicated the resident was seen for diminished hearing, stuffy ears, nasal congestion, throat congestion/clearing. The consultation report revealed, the resident needed hearing aids and had not received them. A Hearing Aid Delivery Report dated 10/08/2024, revealed Resident #24's hearing aid was delivered to the facility and the Social Services Designee (SSD) signed the form to acknowledge receipt of the resident's hearing aids. During a concurrent observation and interview on 12/09/2024 at 9:45 AM, Resident #24 was in a wheelchair, and the resident did not have hearing aids in their ear. Resident #24 stated they did not get their hearing aids. A sign posted at the bedside of the resident directed staff to please charge (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: 056186 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 056186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centinela Grand Inc 2225 North Perris Boulevard Perris, CA 92571 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)