Health inspection·November 15, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to respect the rights of one of the three sampled residents (Resident 1) when a Certified Nurse Assistant (CNA 1) turned on the light in Resident 1 ' s room without her permission on September 28, 2024. This failure had the potential compromise Resident 1 ' s sense of safety and dignity. Findings: During a review of Resident 1 ' s admission Record (contains demographic and medical information) it indicated Resident 1, was initially admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure (the lungs can ' t get enough oxygen into the body), tracheostomy (a medical procedure where a small hole is made in the neck and windpipe to help someone breath), and dependence on respiratory. During a review of Resident 1 ' s Minimum Data Set (MDS), Section C Cognitive Patterns (items in this section are intended to determine the resident ' s attention, orientation and ability to register and recall new information.), dated September 26, 2024, it indicated Resident 1 had a Brief Interview for Mental Status (used to determine functioning used to determine a resident cognitive functioning status) Score of 14 ( a core of 13-15 indicates intact cognition.) During a concurrent observation and interview, on October 9, 2024, at 2:14 PM, Resident 1, stated that CNA 1 entered her room, turned on the overhead light without asking for permission, and dismissed her concern about her medical condition. Resident 1, who was lying in bed with her head elevated to 45 – degree angle in a dimly lit room, expressed that her sensitivity to bright light made it uncomfortable for her when the light was turned on without her consent. During a phone interview on October 9, 2024, at 5:57 PM, with (CNA 1), CNA 1 confirmed that he turned on the light at Resident 1 ' s room without permission on September 29, 2024. CNA 1 acknowledged that he should have asked Resident 1 first to respect her preference. During a concurrent interview and record review on November 11, 2024, at 2:18 PM, with Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled Resident Rights Policy, dated September 2017, was reviewed. The policy indicated Facility must protect promote their rights each resident .To be free from mental and physical abuse .Participate in the development and implementation of his on her person. centered plan of care to include establishing goals and outcomes and to be informed in advance of changes to be plan of care. Also, the right to identify individuals to be included (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 4 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 11/15/2024 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)