Health inspection·March 27, 2025

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 answered timely, for three of five sampled residents, (Residents 1, 3, and 5). Residents Affected - Few This failure had the potential to negatively affect Residents 1, 3, and 5's psychosocial well-being, and could affect the residents' overall health condition. Findings: On March 27, 2025, at 5:32 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. 1. On March 27, 2025, at 6:50 a.m., Resident 3 was observed sitting at the side of the bed in a hospital gown and was watching television. In a concurrent interview with Resident 3, she stated the call lights were usually answered within 20 to 30 minutes from 6 p.m. to early morning. Resident 3 stated when the call lights were not answered at all, she would wheel herself out to the nursing station. On March 27, 2025, Resident 3's record was reviewed. Resident 3's admission Record, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included muscle weakness. Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated March 14, 2025, indicated Resident 3 had a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact), and required assistance in Activities of Daily Living (ADL - bathing, toileting, dressing, and personal hygiene). 2. On March 27, 2025, at 6:52 a.m., Resident 5, was observed lying in bed and watching television. In a concurrent interview with Resident 5, he stated 60 percent of the time he waited for the call light to be answere for 10 minutes or more. Resident 5 stated there was a time when the call light was never answered at all. Resident 5 stated on one occasion he was left in a soiled diaper when he could not transfer himself out of bed. Resident 5 further stated he was disappointed. On March 27, 2025, Resident 5's record was reviewed. Resident 5 ' s admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included gangrene (dead tissue), need for assistance with personal care, legal blindness, multiple sclerosis (disease of nervous system, and ulcer of right heel and midfoot. Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated March 17, 2025, indicated Page 1 of 3 555747 555747 03/27/2025 Murrieta Health and Rehabilitation Center 24100 Monroe Avenue Murrieta, CA 92562

F 0558 Resident 5 had a BIMS score of 15 (cognitively intact), and required assistance in ADLs. Level of Harm - Minimal harm or potential for actual harm 3. On March 27, 2025, at 10:50 a.m., an interview with Resident 1 was conducted. Resident 1 stated she felt there was enough staff help in the day shift but not at night. Resident 1 stated staff did not answer the call light timely. Resident 1 stated it would take over 30 minutes to an hour for the call light to be answered most of the time. Resident 1 stated sometimes the staff answer the call light and sometimes they did not. Resident 1 also stated she mostly uses the call light to get assistance to use the bathroom. Resident 1 further stated more than once she was left soiled because staff did not answer her call light. Resident 1 stated she felt awful, and she just wanted to be clean. Residents Affected - Few Resident 1 ' s record was reviewed. Resident 1 ' s admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included seizure (disturbance of brain function) cyst of the pancreas (fluid filled sac on the pancreas), dysphagia (difficulty swallowing), muscle weakness, difficulty walking and need for assistance with personal care. Resident 1 ' s MDS, dated March 3, 2025, indicated Resident 1 had a BIMS score of 15 which indicated cognitively intact, and Resident 1 required substantial/maximal assistance for toileting. Resident 1 ' s care plan. dated March 19, 2025, indicated a Focus that Resident 1 was at risk for further decline in function status: bed mobility, transfers, locomotion, ambulation, dressing, toileting, hygiene, bathing, and eating, and intervention indicated, anticipate and assist with Activity of Daily Living (ADL) needs, and assist with toileting; keep clean and dry. On March 27, 2025, at 11:33 a.m. observed a licensed nurse sitting at the nurse ' s station 3. The call lights were observed ringing and lit on the board at the nurse station for two rooms. The call lights had been on for over 10 minutes without anyone answering them, and the licensed nurse had to be alerted that the call lights were on. On March 27, 2025, at 12:00 p.m., an interview with the Director Staff Development. (DSD) was conducted. The DSD stated her expectation was that staff answered call lights right away or within 3 to 5 minutes. The DSD stated some negative outcome could be personal needs of the residents would not be met, residents could wet their beds, or resident could develop wounds. The DSD also stated it was not her expectation that a resident wait over 10 minutes for the call light to be answered. The DSD stated any staff could answer the call light. The DSD further stated the call light made a sound, it can be heard, and the room number lit up on the board at the nurses station. On March 27, 2025, at 1:10 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the call lights should be answered in a timely manner and if staff was busy, they could answer the call light, check on the resident and inform them they would follow up. The DON further stated it was everyone ' s responsibility to answer the call lights. The DON stated the call light had a sound and could be heard. A review of the facility ' s policy and procedure titled, Dignity, dated February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being .level of satisfaction with life .and feelings of self-worth and self-esteem .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: promptly responding to a resident ' s request for toileting assistance . 555747 Page 2 of 3 555747 03/27/2025 Murrieta Health and Rehabilitation Center 24100 Monroe Avenue Murrieta, CA 92562

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility ' s undated policy and procedure titled, Answering the Call Light, indicated, .The purpose of this procedure is to ensure timely responses to the resident ' s request and needs .Answer the resident call system immediately .If the resident needs assistance, indicate the approximate time it will take for you to respond . A review of the facility ' s policy and procedure titled, Resident Rights: dated February 2021, indicated, .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility .these rights include the resident ' s right to: a dignified existence .be treated with respect, kindness, and dignity . 555747 Page 3 of 3