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