Health inspection·April 27, 2023

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 call lights were within reach while in bed in accordance with their policy and procedure for two out of three sampled residents (Residents 1 and 2). Residents Affected - Few This failure has the potential to result into a delay in the provision of services and needs not being met for Residents 1 and 2. Findings: 1. During a review of Resident 1's medical record, the Resident Face Sheet (contains demographic and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular disease (a conditions that adversely affect blood flow to the brain, can cause lasting brain damage and long-term disability), chronic systolic congestive heart failure (disease in which heart cannot pump blood efficiently and makes it difficult to breathe), and hypertensive (elevated blood pressure). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated January 30, 2023, indicated Resident 1 was assessed to be in need of extensive assistance (when Staff fully assists the person in accomplishing the task; person is unable to or minimally participates) with 1-person physical assistance with bed mobility, dressing, and personal hygiene. During an observation and concurrent interview, with Resident 1, on March 15, 2023, at 2:30 PM, Resident 1 was in her room, lying down in bed. Resident 1's call light was not within reach. When Resident 1 was asked to reach her call light, Resident 1 stated she was unable to reach her call light. During an observation and concurrent interview, with Certified Nurses Assistance 1 (CNA 1), on March 15, 2023, at 2:40 PM, in Resident 1's room, Resident 1's call light was not within reach of the resident. The resident's call light was clipped to the corner of pillowcase, close to the headboard of her bed, and was dangled down over the head bed frame to the floor. CNA 1 stated call light should be clipped within Resident 1's easy reach. 2. During a review of Resident 2's medical record, the Resident Face Sheet, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular disease,hypertensive, and hyperlipidemia (too many lipids (fats) in the blood). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 has severely impaired cognitive skills for daily decision making. Further review indicated Resident 2 was assessed to be in need of (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: 056444 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 056444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Extended Care Hospital of Montclair 9620 Fremont Ave Montclair, CA 91763 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)