Health inspection·May 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 one of three sampled resident's (Resident 1) call light (a device used by residents to call for assistance from facility staff) was within reach. This deficient practice resulted in Resident 1 looking for but not being able to locate find her call light. This deficient practice had the potential for Resident 1 to get out of bed without assistance causing a fall and injury. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (progressive brain disease that causes a decline in thinking abilities), adult failure to thrive (decline in their overall health and well-being) and a history of falls. During a review of Resident 1's History and Physical (H&P), dated 2/11/2024, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/7/2025, the MDS indicated Resident 1 was usually able to understand and be understood by others. The MDS indicated Resident 1's cognition (ability to register and recall information) was severely impaired. During a review of the Resident 1's Care Plan, revised on 5/10/2025, the Care Plan indicated Resident 1 was at risk for falls related to abnormalities in gait (how a person walks) and balance, a history of falls, dementia (a progressive state of decline in mental abilities), shortness of breath (SOB), a seizure disorder, a history of dizziness, psychotherapeutic medication (medication that affects how one thinks and feels), a need for assistance with activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) adult failure to thrive and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that interferes with daily life). The Care Plan's goals indicated Resident 1 would minimize her risk of falls/injuries through the next review date of 8/7/2025. The Care Plan's interventions included placing Resident 1's call light within reach and encouraging Resident 1 to use it to call for assistance as needed. During an observation accompanied by the Assistant Director of Nursing (ADON) and concurrent interview on 5/27/2025, at 8:27 a.m., Resident 1 was observed lying in bed looking around for something. Resident 1 stated she was looking for her call light but could not find it. Resident 1's call light Page 1 of 2 055894 055894 05/27/2025 Broadway by the Sea 2725 E. Broadway Long Beach, CA 90803

F 0550 Level of Harm - Minimal harm or potential for actual harm was observed between Resident 1's mattress and the fitted sheet toward the top of the bed. The ADON stated, there was no way Resident 1 could reach the call light to ask for assistance and it (the call light) should be accessible to the resident for safety reasons. The ADON stated Resident 1 was at high risk for falls and without the call light, she was unable to call for assistance which increased her risk of falling and injuries. Residents Affected - Few During an interview on 5/9/2024 at 3:30 p.m., the DON stated call lights should be accessible to residents so they could receive care in a timely manner. The DON stated Resident 1's risk for falls and injuries was increased when she does not have a means to ask for assistance, which could result in her trying to get out of bed without assistance and falling. During a review of the facility's undated Policy and Procedure (P/P), titled, Call Light/Bell the P/P indicated it is the policy of the facility to provide the resident a means of communicating with nursing staff. The P/P indicated the staff should place the call device within the resident's reach before leaving the room. 055894 Page 2 of 2