Health inspection·August 21, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure grievances (a perceived wrong or other cause for complaint or protest, especially unfair treatment) made during resident Council (an independent organized group of residents of that facility who meet to discuss concerns, develop suggestions on improving services, and plan social activities) meetings regarding slow call-light response from the 11 p.m. to 7 a.m., shift was promptly addressed and did not negatively affect four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4).This deficient practice had the potential to cause delays in care and as a result of the deficient practice Resident 1, Resident 2, Resident 3, and Resident 4 continued to experience slow response times when pressing the call light during the 11 p.m. to 7 a.m. shift. Resident 1 felt pissed and Resident 2 felt scared due to the slow response times.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Hemiplegia (can't move one side of the body) affecting the left dominant side, contracture of muscle (the permanent shortening and stiffening of muscles, which limits the normal movement of a joint or body part), and osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue).During a review of Resident 1's care plan dated 9/9/2024 titled Resident prefers the following, the care plan indicated a goal of Resident 1 adopting healthy coping practices and interventions that included ensuring Resident 1's call light was within reach and answered promptly.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/2/2025, the MDS indicated Resident 1 was cognitively (relating to or involving the processes of thinking and reasoning) intact. The MDS indicated Resident 1 required a wheelchair and was dependent (helper does all the effort) for toileting hygiene.2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of history of falling and absence of right leg below the knee (right leg missing below the knee).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required a wheelchair and needed supervision or touching assistance (resident requires verbal queues or touching/ steadying while the resident performs the task) for toileting and chair to bed transfers.3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of injury in a motor-vehicle accident and depression (persistent feelings of sadness that can interfere with daily activities).During a review of Resident 3's care plan titled Activities of Daily Living (ADL, activities related to personal care) Function revised on 6/25/2025, the care plan indicated Resident 3 had general weakness and was dependent on staff for toilet use. The goals for Resident 3 included reducing the risk for fall and skin impairments. Interventions for Resident 3 included placing the call light within reach and answering the call light promptly.During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was Residents Affected - Some Page 1 of 3 056007 056007 08/21/2025 Pacific Care Nursing Center 3355 Pacific Place Long Beach, CA 90806

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mildly impaired. The MDS indicated Resident 3 required a wheelchair and required substantial/ maximal assistance (helper does more that half the effort) for toileting hygiene.4. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should, often leading to being unable to control urine).During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had mild cognitive impairment. The MDS indicated Resident 4 required substantial/ maximal assistance for toileting.During a review of Resident 4's care plan titled ADL Functional dated 8/5/2025, the care plan goals were reducing the risk for fall and skin impairments, the interventions included ensuring the call light was within reach and answering the call light promptly.During a review of the facility's grievances, a grievance was filed on 6/30/2025 by Resident 2. The grievance indicated Resident 2 raised concerns regarding delayed answering of call lights especially right during the 11 p.m. to 7 a.m. shift.During a review of the facility's Resident Council minutes dated 7/24/2025, the Resident Council minutes indicated the month prior (June 2025) during the Resident Council meeting the resident's brought concerns regarding slow call light response especially during the 11 p.m. to 7 a.m. shift. During the July 2025 meeting the resident were asked are call lights being answered in a timely manner? and the residents responded call lights were slow to be answered during the 11 p.m. to 7 a.m. Shift. The Resident Council minutes indicated Resident 2 complained she was not getting help to go to the toilet.During an interview on 8/20/2025 at 12:04 p.m., Resident 3 stated there were always issues with the call light being answered during the 11 p.m. to 7 a.m. shift. Resident 3 stated she had waited up to two hours for someone to answer her call light (unknown date) and when the staff (unknown) finally came in, Resident 3 asked what were you doing, sleeping? Resident 3 stated the long call light wait times were frustrating because she can't get out of the bed by herself and she wouldn't be pressing the call light if she did not need something. Resident 3 stated the long call light wait times had been discussed during multiple Resident Council meetings and it was still an ongoing issue.During an interview on 8/20/2025 at 12:41 p.m., Resident 1 stated there is a long call light response time for the 11 p.m. to 7 a.m. shift and sometimes she waited an hour or more to get help when she pressed the call light. Resident 1 stated the medication she takes gives her diarrhea, so she gets pissed that no one answers the call light, and she has to sit and wait in her shit. Resident 1 stated she starts phone calling up to the front desk during the 11 p.m. to 7 a.m. shift when the staff are not answering call lights. Resident 1 stated she was not going to the Resident Council meetings anymore because residents always had the same complaints (about 11 p.m. to 7 a.m. shift) and nothing was changing.During an interview on 8/21/2025 at 12 p.m., Resident 2 stated she was a high fall risk because she only had one leg, and the staff were supposed to supervise her while she tried to get up to the toilet. Resident 2 stated she presses the call light, but the staff take too long to come during the 11 p.m. to 7 a.m. shift, so she gets up to use the restroom by herself. Resident 2 stated she felt scared she might fall because she is getting up alone due to staff taking a long time to answer the call light. Resident 2 stated she made a grievance as well as the residents had made complaints about the 11 p.m. to 7 a.m. shift call lights during Resident Council meeting but it was still happening as recently as last night. Resident 2 stated she waited 45 minutes last night during the 11 p.m. to 7 a.m. shift to get help when she pressed her call light.During an interview on 8/21/2025 at 12:45 p.m., Resident 4 stated the call light waiting times during the 11 p.m. to 7 a.m. shift was long, and she wore diapers, so she had to wait in her 056007 Page 2 of 3 056007 08/21/2025 Pacific Care Nursing Center 3355 Pacific Place Long Beach, CA 90806

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dirty diaper until someone finally came to change her. Resident 4 stated the facility was aware of the complaints against the 11 p.m. to 7 a.m. shift but it was still an ongoing issue.During an interview on 8/21/2025 at 3 p.m., the director of staff development (DSD) stated she attended the Resident Council meetings and was aware of the issue with delayed response time to call lights during the 11 p.m. to 7 a.m. shift. The DSD stated she had been working at the facility for four months and when she started the complaints about call light response times were really bad and now, they are just bad not really bad. The DSD stated the expectation for answering call lights when residents needed something was right away or at least within 10 minutes. The DSD stated the potential outcome of not answering a resident's call light right away was falls, the resident could be sitting in urine or poop for extended periods of time, and the residents may feel terrible.During an interview on 8/21/2025 at 4:10 p.m., the director of nursing (DON) stated she was aware of complaints regarding the 11 p.m. to 7 a.m. call light wait times. The DON stated the potential outcome of extended wait times for call lights was the resident's needs were not being met, patient satisfaction goes down, and increased risk for falls so it was very important to answer call lights right away. The DON stated her staff were in-serviced regarding the long wait times during the 11 p.m. to 7 a.m. shift and the issue still continued. The DON stated her staff were not competent in answering the call lights in a timely manner or the importance of answering the call lights within a timely manner.During a review of the facility's policy and procedure (P&P) titled Call Lights and dated 1/2017, the P&P indicated it was the facility's policy to respond to the resident's requests and needs and call lights should be answered promptly. 056007 Page 3 of 3