Health inspection·October 3, 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, interview and record review the facility failed to have call device (a mechanism used by residents to promptly communicate with staff) within reach for three of five sampled residents (Resident 2, 3 and 4). This failure had the potential to result in an accident and/or injury, and/or delay resident care.During a review Resident 2's admission Record dated 9/29/25 indicated Resident 2 was originally admitted to the facility on [DATE] with diagnosis including dementia (decline in abilities to remember, make judgments, think, or make decisions), abnormalities of gait and mobility, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities)During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 9/4/25 indicated Resident 2 had mild cognitive (ability to think, understand and make daily decisions) impairment and required partial/moderate assistance with most activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 2's care plan for risk for falls and associated injury, dated 6/26/25 indicated, an intervention of call light within easy reach and answer promptly.During a review Resident 3's admission Record dated ---------9/29/25 indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including Guillian-Barre syndrome (a condition in which the body's immune system attacks the nerves, causing weakness and numbness that gets progressively worse), dysphagia (trouble swallowing), candidiasis (fungal infection cause by a yeast-like fungus) and muscle weakness. During a review of Resident 3's MDS dated [DATE] indicated Resident 3 had mild cognitive (ability to think, understand and make daily decisions) impairment and required supervision or touching assistance to dependance on staff for assistance with most ADLs. During a review of Resident 3's care plan for risk for falls and injuries dated 9/14/25 indicated Maintain call light within reach.During a review Resident 4's admission Record dated ---------9/29/25 indicated Resident 4 was admitted to the facility on [DATE] with diagnosis including hypertension (HTN, high blood pressure), major depressive disorder, Wernicke's encephalopathy (severe, acute brain disorder caused by a deficiency of thiamine [vitamin B1]), and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). During a review of Resident 4's MDS dated [DATE] indicated Resident 4 had severe cognitive impairment and required supervision or touching assistance to partial / moderate assistance by staff for most ADLs.During a review of Resident 4's care plan for risk for falls dated revised 8/30/25 indicated call light within easy reach and answer promptly.During an observation with concurrent interview on 9/29/25 at 2:55 pm with Registered Nurse Supervisor ( RNS) 1 in Resident 2, 3 and 4's room. RNS 1 verified the call light from that room was not illuminating at the call light panel at the nurses' station which would indicate one of the residents in that room needed Residents Affected - Few Page 1 of 2 055748 055748 10/03/2025 Sunset Park Healthcare 2250 29th Street Santa Monica, CA 90405

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance. RNS 1 further verified Resident 3 was given a table bell to use as an alternate way of alerting the staff she needed help, and Residents 2 and 4 did not have a table bell or alternate way to get the attention of the staff while their call lights were out of order. RNS 1 stated the risk to the residents would be the staff would not be aware to address issues on time. During a review of the facility's policy and procedures Call Light, revised October 2024, indicated, When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 055748 Page 2 of 2