Health inspection·January 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 4) when the facility failed to provide timely incontinent (having little or no control over urination or defecation) care (assistance in cleaning up a resident after toileting in a brief [adult diaper]) to Resident 4. Resident 4 was left to sit in a soiled, wet brief for an hour. This deficient practice resulted in Resident 4 feeling uncomfortable, embarrassed , frustrated and neglected by staff. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (DM-disorder characterized by difficulty in blood sugar control and poor wound healing) , muscle weakness and major depressive episode (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 4 had moderate impairment and is usually understood by others. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) from staff with hygiene, toileting, shower and bathing and dressing. The MDS indicated Resident 4 has occasional urine and bowel incontinence (inability to control urge urinate or have bowel movements) . During a concurrent observation and interview on 1/24/25 at 8:15 a.m., with Resident 4, in Resident 4 ' s room, Resident 4 was observed to be sitting in a wheelchair next to her bed. Resident 4 stated she used her call button to call a Certified Nurse Aide (CNA) last night. Resident 4 stated she often waits greater than 30 minutes to receive care. Resident 4 stated it seems the CNAs are too busy and the Licensed Vocational Nurses (LVN)s and Registered Nurses (RN)s do not provide incontinent care, the staff answers wait for your CNA she is coming. Resident 4 stated she felt embarrassed, uncomfortable and neglected at having to wait. Resident 4 stated I have complained regarding the amount of time I have to wait for assistance to the charge nurses but no one does anything. During a review of the facility's Resident Council Minutes, dated 10/22/2024, the minutes indicated call lights are not being answered in a timely way. The minutes indicated when residents ask for CNA, the staff responds, I am not your CNA. Page 1 of 3 055387 055387 01/24/2025 Edgewater Skilled Nursing Center 2625 East Fourth Street Long Beach, CA 90814

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's Resident Council Minutes, dated 11/21/2024, the minutes indicated residents would like to be checked more by nursing. During a review of the facility's Resident Council Minutes, dated 12/19/2024, the minutes do not indicate old business (minutes from the last meeting were read and discussed) concerns from 10/22/2024 and 11/19/2024 were addressed. During an interview on 1/24/2024, at 3 p.m. the Director of Nursing (DON) stated the facility must accommodate the toileting needs of the residents in a timely manner. The DON stated the nursing staff which includes CNAs, licensed nurses and registered nurses, must check on residents at least every two hours or more frequently as requested by the resident. The DON stated by not aiding Resident 1 timely, the facility put Resident 1 at risk for urinary tract infections (UTIs-infection in any part of the urinary system [parts of the body responsible for removing urine]) and skin breakdown. The DON stated sitting in a wet and soiled brief can cause frustration and embarrassment for a resident, which does not preserve dignity. The DON stated the licensed nurses, and registered nurses must provide all care including incontinent care to residents. During a review of the facility's policy and procedure (P/P) titled, Dignity , revised 2/2021, the P/P indicated each resident shall be cared for in a manner that promotes and enhanced his/ her sense of well-being, level of satisfaction with life , and feelings of self-worth and self-esteem. The P/P indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and respect for example, promptly responding to resident ' s request for toileting assistance. During a review of the facility's P/P titled, Call Light , revised 5/2007, the P/P indicated it is the policy of this facility to provide residents a means of communicating with nursing staff, the procedure is as follows: answer the call light/ bell within a reasonable time. The P/P indicated respond to residents ' request, if the item is not available for you or you are unable to assist, explain to the resident and notify the charge nurse for further instructions. Based on observation, interview and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 4) when the facility failed to provide timely incontinent (having little or no control over urination or defecation) care (assistance in cleaning up a resident after toileting in a brief [adult diaper]) to Resident 4. Resident 4 was left to sit in a soiled, wet brief for an hour. This deficient practice resulted in Resident 4 feeling uncomfortable, embarrassed , frustrated and neglected by staff. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (DM-disorder characterized by difficulty in blood sugar control and poor wound healing) , muscle weakness and major depressive episode (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 4 had moderate impairment and is usually understood by others. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) 055387 Page 2 of 3 055387 01/24/2025 Edgewater Skilled Nursing Center 2625 East Fourth Street Long Beach, CA 90814

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some from staff with hygiene, toileting, shower and bathing and dressing. The MDS indicated Resident 4 has occasional urine and bowel incontinence (inability to control urge urinate or have bowel movements) . During a concurrent observation and interview on 1/24/25 at 8:15 a.m., with Resident 4, in Resident 4's room, Resident 4 was observed to be sitting in a wheelchair next to her bed. Resident 4 stated she used her call button to call a Certified Nurse Aide (CNA) last night. Resident 4 stated she often waits greater than 30 minutes to receive care. Resident 4 stated it seems the CNAs are too busy and the Licensed Vocational Nurses (LVN)s and Registered Nurses (RN)s do not provide incontinent care, the staff answers wait for your CNA she is coming. Resident 4 stated she felt embarrassed, uncomfortable and neglected at having to wait. Resident 4 stated I have complained regarding the amount of time I have to wait for assistance to the charge nurses but no one does anything. During a review of the facility's Resident Council Minutes, dated 10/22/2024, the minutes indicated call lights are not being answered in a timely way. The minutes indicated when residents ask for CNA, the staff responds, I am not your CNA. During a review of the facility's Resident Council Minutes, dated 11/21/2024, the minutes indicated residents would like to be checked more by nursing. During a review of the facility's Resident Council Minutes, dated 12/19/2024, the minutes do not indicate old business (minutes from the last meeting were read and discussed) concerns from 10/22/2024 and 11/19/2024 were addressed. During an interview on 1/24/2024, at 3 p.m. the Director of Nursing (DON) stated the facility must accommodate the toileting needs of the residents in a timely manner. The DON stated the nursing staff which includes CNAs, licensed nurses and registered nurses, must check on residents at least every two hours or more frequently as requested by the resident. The DON stated by not aiding Resident 1 timely, the facility put Resident 1 at risk for urinary tract infections (UTIs-infection in any part of the urinary system [parts of the body responsible for removing urine]) and skin breakdown. The DON stated sitting in a wet and soiled brief can cause frustration and embarrassment for a resident, which does not preserve dignity. The DON stated the licensed nurses, and registered nurses must provide all care including incontinent care to residents. During a review of the facility's policy and procedure (P/P) titled, Dignity , revised 2/2021, the P/P indicated each resident shall be cared for in a manner that promotes and enhanced his/ her sense of well-being, level of satisfaction with life , and feelings of self-worth and self-esteem. The P/P indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and respect for example, promptly responding to resident's request for toileting assistance. During a review of the facility's P/P titled, Call Light , revised 5/2007, the P/P indicated it is the policy of this facility to provide residents a means of communicating with nursing staff, the procedure is as follows: answer the call light/ bell within a reasonable time. The P/P indicated respond to residents' request, if the item is not available for you or you are unable to assist, explain to the resident and notify the charge nurse for further instructions. 055387 Page 3 of 3