Health inspection·February 13, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 1) needs were accommodated promptly, when Resident 1's call light was not within her reach. Residents Affected - Few This failure had the potential of Resident 1's needs not being met and to cause psychosocial and/or physical harm for Resident 1 when Resident 1 was unable to contact staff for assistance if needed. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in early 2024 with multiple diagnoses including unsteadiness, and muscle weakness. Review of Resident 1's admission assessment titled, Nursing Documentation Evaluation dated 2/3/24, indicated, .Fall Risk indicators Identified .ABLE TO MAKE NEEDS KNOWN .1 PERSON ASSIST WITH ADLS [Activities of Daily Living] .CALL LIGHT WITHIN REACH, INSTRUCTED TO CALL FOR ASSISTANCE . Review of Resident 1's Change in Condition Evaluation record dated 2/4/24, indicated, .Pt. [Patient] noted on floor next to bed with back resting on side of bed. Pt. stated took brief off due to had an incontinent [lacks bowel/bladder control] episode, pt. attempted to get up and slid on her BM [Bowel Movement]. Denies hitting head but noted indentation across mid back from bed frame where she was resting her back .Pt. assisted back to bed with 2 staff assistance and pt. cleaned by CNA. Encouraged to use call light for assistance . During an observation on 2/12/24, at 2:29 p.m., Resident 1 was lying in bed in her room. Resident 1's call light was coiled up to the wall and was not within her reach. During a concurrent interview and record review on 2/12/24, at 3:13 p.m. Certified Nursing Assistant (CNA) 1 stated Resident 1 needed assistance with transfers and to use the bathroom. CNA 1 stated staff educated her to use the call light to call for assistance when needed. CNA 1 stated Resident 1 understood and used the call light to call for staff help when needed. CNA 1 confirmed Resident 1's call light was coiled up to the wall and was not within Resident 1's reach. CNA 1 stated the call light should be within the residents reach at all times because residents could not move much and could not reach the call light at the wall if they needed help. CNA 1 further stated residents could fall on the floor. CNA 1 added residents would not be able to call staff for assistance if they fell when the call light was not within reach and could remain on the floor for a long time without staff knowing. CNA 1 stated the call light should be within residents reach at all times so that staff can assist residents promptly when needed. Page 1 of 2 555387 555387 02/13/2024 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/12/24, at 3:46 p.m., Licensed Nurse (LN) 1 stated Resident 1 needed assistance with transfers and to use the bathroom. LN 1 stated Resident 1 knew how to use the call light and had been using the call light. LN 1 stated Resident 1's call light should be within her reach at all times for her safety, to call for help if she needed something, to prevent falls, and to meet her needs. During an interview on 2/12/23, at 6:28 p.m., the Director of Nursing (DON) stated Resident 1 was at risk for falls and had fallen on 2/4/24. The DON stated the call light should be within reach so that residents could use it when assistance was needed, to prevent falls, and to meet their needs. The DON stated if a resident's call light was not within reach the resident would try to reach for it and could end up on the floor. The DON further stated with a call light out of reach, a resident would not be able to call for help to use the bathroom and could have an accident on themselves, and the resident's needs would not be met. Review of Resident 1's care plan dated 2/5/24, indicated, .Resident had a unwitnessed fall on 2/4/2024 cognitive loss lack of safety awareness, Impaired mobility .Interventions .- Remind resident to use call light when attempting to ambulate or transfer .place all necessary personal items within reach . Review of a facility policy titled Answering the Call Light revised September 2022, indicated, .The purpose of this procedure is to ensure timely responses to the resident's requests and needs .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor . 555387 Page 2 of 2