Health inspection·December 22, 2023

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 provide a functioning call light (device to call for assistance from staff) for one of three sampled residents (Resident 1) as indicated in the Call System Communication facility policy. Residents Affected - Few This failure had the potential to result in Resident 1 not being able to call the facility staff for assistance, which could result in a fall, injury or delayed provision of care. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included hemiplegia (unable to move only one side of the body) and hemiparesis (one-sided muscle weakness) after a cerebral infarction (a condition that disrupts blood flow to the brain) affecting the left dominant side, absence of a right forearm below the right elbow, diabetes mellitus (a condition when the body cannot properly store or use glucose [sugar]), hypertension (high blood pressure), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood), and coronary artery disease (condition that restricts the blood supply to the heart). During a review of Resident 1 ' s History and Physical (H&P), dated 12/14/23, the H&P indicated Resident 1 had the mental capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive assessment of each resident ' s functional capabilities and identifies health problems), dated 12/11/23, indicated Resident 1 was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. MDS also indicated Resident 1 required maximum assistance with sitting to standing and transferring from chair to bed. During a concurrent observation and interview on 12/22/23 at 1:45 pm in Resident 1 ' s room, Resident 1 attempted to use the call light but was unable to push the red button down to call for staff. The red button was seen through the opening at the top of the device to be jammed to the bottom of the call light. Resident 1 stated the call light button has been stuck for about four to five days. Resident 1 stated, I feel so alone, and I feel like I have no voice .I get worried if something might happen to me because I can ' t call anyone. During an interview on 12/22/23 at 1:30 pm with Certified Nursing Assistant (CNA) 1, CNA 1 stated the call light button for Resident 1 was stuck at the bottom of the device. CNA 1 stated it was unacceptable to have a non-functioning call light in an isolation room because the door needs to be Page 1 of 2 055548 055548 12/22/2023 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0919 closed, and the resident wouldn ' t be able to call staff for assistance. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/22/23 at 3:07 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated maintenance needs to be notified if the call light is not working. LVN 1 further stated it is not safe for residents to not have a working call light in an isolation room because residents wouldn ' t have a way to communicate to staff of residents needs or if the resident is experiencing an emergency. Residents Affected - Few During an interview on 12/22/23 at 3:40 pm with the Director of Nursing (DON), the DON stated that the call light is mandatory for Coronavirus disease 2019 (Covid 19, a highly contagious virus that spreads quickly and affects the lungs and other parts of the body) positive residents because the door is closed for isolation. The DON stated that the call light should have been replaced immediately to ensure Resident 1 can notify staff of his needs. The DON further stated, a non-functioning call light can risk the safety of the resident, especially if the resident is placed in isolation. During a review of facility ' s policy and procedure (P&P) titled, Communication-Call System, dated 1/1/2012, the P&P indicated if the call bell is defective, it will be reported immediately to maintenance and replaced immediately. 055548 Page 2 of 2