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Inspection visit

Health inspection

EDGEWATER SKILLED NURSING CENTERCMS #0553871 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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. (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 3 Event ID: 055387 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 055387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewater Skilled Nursing Center 2625 East Fourth Street Long Beach, CA 90814 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)
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) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055387 If continuation sheet Page 2 of 3 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 055387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewater Skilled Nursing Center 2625 East Fourth Street Long Beach, CA 90814 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)
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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055387 If continuation sheet Page 3 of 3

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0550GeneralS&S Epotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

FAQ · About this visit

Common questions about this visit

What happened during the January 24, 2025 survey of EDGEWATER SKILLED NURSING CENTER?

This was a inspection survey of EDGEWATER SKILLED NURSING CENTER on January 24, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at EDGEWATER SKILLED NURSING CENTER on January 24, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.