Health inspection·May 16, 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 place the call light buttons for 4 of 6 sampled residents (Residents 2, 4, 5 and 6), within their reach. Residents Affected - Some This deficient practice placed Residents 2, 4, 5, and 6 at risk for not being able to call for help when needed and can result to needs not being attended to timely. This deficient practice had the potential to cause falls, other injuries, including hospitalization and death. Findings: During an inspection of the facility, on 5/16/25 at 10:45 am, the call light buttons in each residents ' room were inspected along with the Assistant Director of Nursing (ADON) for functioning and placement. Resident 2, the call light button was observed at the head of Resident 2 ' s bed, behind the pillow, Resident 2 could not reach the call light button. Resident 4, the call button was observed on the floor away from Resident 4 ' s reach. Residents 5, and 6, the call light button was on the bed away from Resident ' s reach. a). During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a condition where the heart can't pump enough blood to meet the body's needs), kidney failure (Resident 2 occurs when the kidneys are no longer able to effectively remove waste and excess fluid from the blood), Resident 2 had a history of falling. During a review of Resident 2 ' s Minimum data Set ([MDS] a comprehensive resident assessment and care-screening too) dated 4/7/2025, the MDS indicated Resident 2 has some cognitive impairment, but can make her needs known. MDS indicated Resident 2 needs assistance with mobility and transfer from bed to chair. During a review of Resident 2 ' s nurses note on 3/13/2025 and 3/18/2025, the nurse ' s notes indicated Resident 2 had a fall incident on 3/13/2025 and 3/18/2025. During a review of Resident 2 ' s care plans to minimize and prevent falls, one of the interventions indicatedto place Resident 2 ' s call light button within resident ' s reach and encourage Page 1 of 2 555306 555306 05/16/2025 Kei-Ai South Bay Healthcare Center 15115 S Vermont Ave Gardena, CA 90247

F 0919 resident to use the call light button. Level of Harm - Minimal harm or potential for actual harm During interview on 5/16/2025 at 10:45 a.m., with Resident 2, Resident 2 stated that she cannot reach her call light button. Residents Affected - Some b). During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including Epilepsy (a neurological disorder characterized by recurrent seizures), Osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and Hypertension (HTN-high blood pressure). During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated Resident 4 had the ability to make her needs known and needs assistance with transfer from bed to chair. During an interview on 5/16/2025 at 1:20 p.m., with Resident 4, Resident 4 stated that she needs the call light button close to her, so she can call for help when she needs help. During an interview on 5/16/2025 at 1:30 p.m., with a Certified Nurse Assistant (CNA 1), CNA 1 stated that she placed the call light button on Resident 2 ' s bed within her reach after cleaning up the resident. CNA 1 stated that call button must have fallen to the floor. c). During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including Encephalopathy (any brain disorder that affects its function or structure, leading to an altered mental state), Schizophrenia ((a mental illness that is characterized by disturbances in thought), and HTN. During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated Resident 5 had some cognitive impairment. The MDS indicated Resident 5 needs assistance with transfer from bed to chair. d). During a review of Resident 6 admission record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including Dementia (a progressive state of decline in mental abilities), Dysphasia (difficulty swallowing), and contracted right hand. During a review of Resident 6 ' s MDS dated [DATE], the MDS indicated Resident 6 had some cognitive impairment. The MDS indicated Resident 6 needs assistance with transfer from bed to chair. During an interview on 5/16/2025 at 1:50 p.m., with CNA 2, CNA 2 stated that the call light button was not placed within reach for Residents 5 and 6 because both residents cannot use the call light button. During an interview on 5/16/2025 at 2:10 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated the residents ' call lights should be placed within reach so that the residents can call for help when needed. During a review of the facility ' s policy and procedure (P&P) titled, Call Light Answering, dated 12/2021, the P&P indicated that it is the policy of the facility to provide the residents a means of communication with the nursing staff. The P&P indicated to place the call device within resident ' s reach before leaving the room. 555306 Page 2 of 2