Health inspection·May 6, 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 and interview, the facility failed to ensure resident 's call light was within reach, for one of three sampled residents out (Resident 1). Residents Affected - Few This failure could have resulted in Resident 1 not receiving nursing assistance when needed. Findings: On April 14, 2025, at 750 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1, who stated, the residents use their call lights to request help from nursing staff. CNA 1 stated, the call light should always be within reach of the resident. On April 16, at 1105 a.m., a concurrent observation and interview of Resident 1 were conducted. Resident 1 was heard calling out from the room for staff assistance. Resident 1 was then observed in his room sitting in a reclining chair, with his legs and feet up, the chair was horizontal to the foot of his bed. Resident 1 ' s call light was at the head of the bed, out of reach from resident. Resident 1 stated, I ' ve been here too long, I want to go to bed. On April 16, 2025, at 11:18 a.m., a concurrent observation of Resident 1 and interview with CNA 2 was conducted. CNA 2 stated, the call lights should always be within reach of the resident so they can call for assistance. CNA 2 observed Resident 1 in his room, reclining in the chair, and stated, Oh (Resident 1 ' s) back, he was just in the dining room somebody must have put him in his room I think from activities (department). CNA 2 verified (Resident 1 ' s) call light was not within reach, and resident had no way to call for staff ' s assistance. Resident 1 stated, I want to go to bed. On April 16, 2025, at 1132 a.m., an interview was conducted with the Activity Assistant (AA), who stated, after activities group, she returned Resident 1 to his bedroom and placed him at the foot of the bed in his reclining chair. The AA stated, when she returned Resident 1 to his bedroom, she hit the call light to inform the nursing staff resident was back to his room from activities. The AA stated, she returned to the activities department without waiting for nursing staff to answer resident ' s call light, to hand off resident 's care. The AA stated, I had to get back to the activity room to monitor the residents. The AA could not explain the process of the call lights and residents ' use for assistance. On April 16, 2025, at 11:42 a.m., an interview was conducted with the Activities Director (AD), who stated, when activity staff return a resident back to their unit, they are to take the resident directly to the nursing station and hand off care to nursing staff via communication. If a resident is returned to their room, care must be handed off to a member of nursing staff, prior to leaving the Page 1 of 2 555921 555921 05/06/2025 Rancho Bellagio Post Acute 26940 E Hospital Road Moreno Valley, CA 92555

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident in their bedroom. The AD verified, Resident 1 should not have been left in his room by AA, without communicating to staff resident had returned to his bedroom. The AD further stated, Resident 1 's call light should have been within resident 's reach. On April 22, 2025, at 4:26 p.m., an interview conducted with the Director of Nursing (DON), who stated, call lights should always be within the residents reach. DON further stated, activity staff should communicate to nursing staff resident has been returned to the unit/bedroom, and the call light should be left within resident 's reach. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal level of blood sugar) and hemiplegia (a condition characterized by paralysis of one side of the body) and hemiparesis (a condition characterized by weakness or partial loss of strength on one side of the body). A review of Resident 1's care plan dated January 30, 2025, indicated, .ADL (activities of daily living)/Mobility .at risk for ADL/Mobility decline and requires assistance related to bed-bound status .Interventions .Encourage to use call light for assistance . A facility Policy & Procedure, titled, Call Lights, revised, October 2010, indicated, . Purpose: . is to respond to the resident ' s requests and needs. General Guidelines: . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . 555921 Page 2 of 2