Inspection·May 23, 2023

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 the call light was within reach for one resident (Resident 1) of three sampled residents. Residents Affected - Few This failure decreased the potential for Resident 1 to get assistance from staff in a timely manner when needed. Findings: A review of an admission record indicated, Resident 1 was admitted to the facility on [DATE], and discharged on 5/17/23, with diagnoses including acute respiratory failure (caused by a disease or injury that affects your breathing), shortness of breath, and dependence on supplemental oxygen. A review of Resident 1's Minimum Data Set (MDS; an assessment tool), dated 4/27/23, indicated, BIMS (Brief Interview of Mental Status) score of 15 with no memory problems. A review of a facility document dated 5/13/23, indicated, Resident 1 sat in her wheelchair from 4:30 a.m. until 7 a.m. The Certified Nursing Assistant 1 (CNA 1) who placed Resident 1 in the wheelchair did not return to check on the resident, and the call light was pinned to the window blinds out of Resident 1's reach. During an interview on 5/23/23, at 12:51 p.m., with the Business Office Manager (BOM), BOM stated Resident 1 reported to me on 5/13/23, around 10 a.m. that CNA 1 left her in the wheelchair from 4:30 a.m. till 7 a.m., the call light was not within her reach and was pinned to the window blinds. She further stated CNA 1 did not check if Resident 1 had her call light within reach. During a phone interview on 5/25/23, at 8:22 a.m., with CNA 1, CNA 1 stated Resident 1 asked to be transferred from bed to wheelchair, so she did that and then placed the table in front of Resident 1 so she could watch TV. CNA 1 further stated she did not remember how much time Resident 1 stayed in her wheelchair and if she placed the call light at her bedside within reach. During a concurrent observation and interview on 5/23/23, at 12:23 p.m., with CNA 2, in Resident 1's room, Resident 1's bed was located between Resident 1's wheelchair and the room's window and the window blinds were not within reach. CNA 2 stated, when she arrived on 5/13/23, at 7 a.m., she observed Resident 1 sitting in her wheelchair facing the TV, her call light was pinned to the window blinds, and Resident 1 could not reach it. A review of Resident 1's care plan, dated 5/13/23, indicated, call light placed within reach. (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: 555555 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 555555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608 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)