Health inspection·May 21, 2025

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 ensure one out of seven sampled residents ( Resident 7) was provided a funtioning call light. Residents Affected - Few This deficient practice had the potential to result in a delay in care and untimely response for Resident 7. Findings: A review of Resident 7 ' s admission Record indicated the resident was admitted to the facility on [DATE], with a diagnosis that included Dysphagia (difficulty with verbal communication) and Anxiety ( feelings of being worried or nervous). A review of Resident 7 ' s Minimum Data Set ( MDS, a resident assessment tool) dated 05/13/2025, indicates resident has moderate cognitive impairment ( decline in memory, attention, language, function) and requires moderate assistance ( helper does more that half the effort ) for activities of daily living such as oral hygiene, toileting hygiene, and dressing. A review of Resident 7 ' s Care Plan Titled Ophthalmology Consult, dated 05/07/2025, indicated a goal for Resident 7 to not have any falls or bruising related to impaired vision. The Care Plan indicated an intervention to have call lights within reach. A review of Resident 7 ' s Care Plan Titled Resident 7 has a communication problem related to impaired ability to understand and be understood sometimes, dated 05/14/2025, indicated to ensure and provide a safe environment with call light within reach, adequate low glare light, bed in lowest position and wheels locked and to avoid isolation. A review of Resident 7 ' s Care Plan Titled Resident 7 is at risk for falls related to adverse reactions from medications dated 05/08/25, indicated to ensure Resident 7 ' s call light was within reach and to encourage the resident to use the call light for assistance as needed. During an observation on 5/21/2025 at 10:40AM in resident 7 ' s room, Resident 7 ' s call light was observed on the floor and not within Resident 7 ' s reach. During an interview on 5/21/2025 at 10:40 AM with Resident 7, Resident 7 stated the call light did not work. During a concurrent observation and interview on 05/21/2025 AM, with certified nursing assistant ( (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 2 Event ID: 056317 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 056317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202 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)