Health inspection·May 9, 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 the call light system was functioning properly for 2 residents (Resident 1 and Resident 2) residing in room [ROOM NUMBER]. Residents Affected - Few This failure had the potential to result in residents' needs not being met and prevent residents' communication for assistance when needed. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses which included displaced comminuted fracture of left patella (kneecap was broken into multiple pieces and pieces were not properly aligned). During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), the MDS indicated Resident 1 had moderate cognitive impairment. During a review of Resident 2 ' s AR, the AR indicated Resident 2 was admitted on [DATE] with diagnoses which included surgical aftercare following surgery on the digestive system. During a review of Resident 2 ' s MDS, the MDS indicated Resident 2 had moderate cognitive impairment. During a concurrent observation and interview on 5/9/25 at 10:57 a.m. with Resident 1 in room [ROOM NUMBER], Resident 1 ' s call light was activated but the light above the door did not turn on, and the call light panel at the nurse ' s station did not show the call. Resident 1 stated the call light had not worked since she was admitted and that she was not given a call bell. Resident 1 said she waited for someone to walk by her room and called out when she needed help. During an interview on 5/9/25 at 11:06 a.m. with Resident 2, Resident 2 stated she had experienced problems with her call light not working. Resident 2 stated that when she pushed the button, most of the time no one came, and sometimes she waited up to two hours for assistance. During a concurrent observation and interview on 5/9/25 at 11:11 a.m. with the Director of Nursing (DON), Resident 1 ' s call light was activated, but the light above the door did not turn on. DON confirmed that the call light was not working. During a concurrent observation and interview on 5/8/25 at 11:16 a.m. with Director of Staff Development (DSD) in room [ROOM NUMBER], DSD stated the button on the call light cord was not working. The Page 1 of 2 555333 555333 05/09/2025 Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DSD was observed replacing it with a new cord. The DSD then activated the call light using the new cord and confirmed that it was still not working. During a concurrent observation and interview on 5/9/25 at 11:39 a.m. with Registered Nurse (RN) 1 in room [ROOM NUMBER] ' s bathroom, RN 1 pulled the string for the emergency call light in the restroom, but it did not turn on. RN 1 attempted to activate it three more times, but it still did not work. RN 1 stated the call light was not working, and explained that if it was working, there would be a beeping sound, the light on the panel in the bathroom would turn on, and the light above the room door would illuminate. At 11:43 a.m. RN 1 attempted to activate the call light again. The first two attempts did not work. On the third attempt, RN 1 pulled the string down hard, and the call light activated. RN 1 stated that the string had to be pulled very hard for it to work and that it needed to be fixed. RN 1 stated that the call light should be activated easily. RN 1 stated that bathroom call lights are important for resident safety so that residents can call for help when they need assistance. During an interview on 5/9/25 at 12:09 p.m. with DON, DON stated the expectation is for call lights to always be functioning. The DON stated call lights are in place for resident safety and to allow staff to respond to residents ' needs. The DON stated that if a call light is not working, or if it is difficult to activate, it could lead to potential harm. During a review of the facility ' s policy and procedure (P&P) titled, Call Systems, Residents dated 9/22, the P&P indicated, .the resident call system remains functional at all times . 555333 Page 2 of 2