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 ( Page 1 of 2 056317 056317 05/21/2025 Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA)1 in resident 7 ' s room , Resident 7 ' s call light was observed on the floor. CNA 1 pressed Resident 7 ' s call light, but the call light did not work. There was not light observed or sound heard when CNA 1 pressed Resident 7 ' s call light. CNA1 stated the button on the call light was not functional and could not be pressed. CNA1 stated it was important that the resident ' call lights were functional since that was how the resident called for assistance when staff were not in residents ' rooms. CNA 1 stated the call light alerted staff when a resident required assistance. During a concurrent observation and interview on 05/21/2025 at 10:50AM, with Registered Nurse (RN)1, in resident 7 ' s room, Resident 7 ' s call light was observed. RN 1 stated Resident 7 ' call light button was not functional since the button was stuck and could not be pressed. RN 1 stated it was crucial to have a working call light so that residents could alert facility staff when assistance was needed. During an interview with Maintenance Supervisor ( MS) on 05/21/2025 at 11:37 AM , stated he conducted weekly inspections to ensure all residents ' call lights were functioning properly. MS stated he maintained a binder to document any issues, including malfunctioning call lights, and that the binders were located in nursing station 1 and station 2, where staff ccoul report maintenance needs. The Maintenance Supervisor reported that the last documented check of Resident 7 ' s call light was conducted on 05/15/2025, with no issues. MS stated he had not received any reports or notifications regarding Resident 7 ' s non functioning call light. A review of the facility ' s policy and procedure titled, Communication Call System, revised October 24, 2022, the policy stated the purpose was to provide a mechanism for residents to promptly communicate with nursing staff. The Policy further indicated that should the primary call system become inoperable for any reason, the facility shall provide an alternative call system to enable residents to alert nursing staff from their beds and toileting/ bath facilities. Additionally, the policy required that defective call bells be reported immediately to maintenance and replaced immediately , and that hourly resident safety checks be conducted and documented until the primary call system is restored. 056317 Page 2 of 2