Health inspection·August 22, 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 ensure two of eleven sampled residents' (Resident 4 and Resident 5) call lights were within reach. Residents Affected - Few This failure has the potential for Resident 4 and Resident 5 to have unmet needs due to inability to be able to call for assistance. Findings: On August 22, 2024, at 11:20 a.m., an unannounced visit to the facility was conducted for the investigation of two Facility Reported Incidents and one complaint. On August 22, 2024, at 12:48 p.m., a concurrent observation and interview was conducted with Resident 4. Resident 4 was sitting on the right side of her bed in her wheelchair. Resident 4 ' s call light was hanging above the right side of the head of the bed. Resident 4 stated she needed help to be changed and was not able to call for help. Resident 4 stated she was unable to reach her call light. On August 22, 2024, at 12:59 p.m., observed Resident 5 sitting in her wheelchair on the right side of the foot of Resident 4 ' s bed. Resident 5 ' s call light was sitting in the center of the bed, out of her reach. On August 22, 2024, at 12:59 p.m., an interview was attempted with Resident 5. Resident 5 was unable to answer questions. On August 22, 2024, at 1:05 p.m. an interview was conducted with the Certified Nursing Assistant (CNA). The CNA stated that while residents are sitting in their rooms in a wheelchair their call lights should be within reach. The CNA stated Resident 4 and Resident 5 were unable to reach their call lights. A review of Resident 4 ' s medical records indicated she was admitted on [DATE], with diagnoses of diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), osteoarthritis (a progressive disorder of the joints caused by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the joints), and peripheral vascular disease (condition in which arteries outside the heart become narrowed or blocked). A review of Resident 4 ' s History and Physical dated November 17, 2023, indicated she had fluctuating capacity to make decisions. Page 1 of 2 555135 555135 08/22/2024 Highland Springs Care Center 1441 Michigan Avenue Beaumont, CA 92223

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 4 ' s Care Plan revised December 27, 2022, indicated Focus: Resident has self care deficits: Extensive assistance . related to . muscular weakness, poor balance, poor safety awareness, unsteady gait .Interventions . Call light within reach and attend needs promptly . A review of Resident 5 ' s medical record indicated she was admitted on [DATE], with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), diabetes mellitus type 2, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a chronic condition characterized by an excessive and persistent sense of apprehension), and history of falling. A review of Resident 5 ' s History and Physical dated May 17, 2024, indicated she could not make decisions. A review of Resident 5 ' s Care Plan dated July 11, 2024, indicated Focus . Resident has self care deficits: Extensive assistance . related to: cognitive deficits, communication deficits, muscular weakness, poor balance, poor safety awareness, unsteady gait . intervention Call light within reach and attend needs promptly . A review of the facility ' s policy and procedure titled Call Lights dated September 2022, indicated .1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor . 555135 Page 2 of 2