F 0558
Reasonably accommodate the needs and preferences of each resident.
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 a resident's call light (an alerting
device for nurses or other nursing personnel to assist a patient when in need) was within easy reach for
one of three (3) sampled residents, (Resident 2). This deficient practice had the potential to cause delay or
not able to provide care and services for Resident 2's requests and needs to maintain Resident 2's safety
and highest wellbeing.During a review of Resident 2's admission Record indicated Resident 2 was admitted
to the facility on [DATE], and readmitted on [DATE], with diagnoses that included but not limit to type II
diabetes mellitus (a chronic condition that happens when you have persistently high blood sugar levels.
Insulin resistance is the main cause, and it has resulted in a condition where the kidneys are damaged and
can't function properly), rheumatoid arthritis (a chronic progressive disease causing inflammation in the
joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles),
and spinal stenosis lumbar region without neurogenic claudication [refers to the narrowing of the spinal
canal in the lower back, which compresses the spinal nerves but does not cause the characteristic
symptom of neurogenic claudication (pain and cramping in the legs with walking or standing, relieved by
bending forward.) Instead, patients may experience other symptoms like back pain, leg pain, or numbness
and tingling in the legs]. During a review of Resident 2's Minimum Data Set (MDS- a mandated resident
assessment tool), dated 6/13/2025, indicated Resident 2 had moderate impairment for cognitive skills (the
function of the brain uses to think, pay attention, process information, and remember things), she can make
her own daily decision. Resident 2 was able to follow commands. Resident 2 needs partial/moderate
assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides
less than half the effort) to complete the activity for oral hygiene, toileting hygiene, personal hygiene,
shower/bathe self, upper and lower body dressing, change of position, and transfer. During a concurrent
observation and interview in Resident 2's room on 8/12/2025 at 10:19 AM with Resident 2, observed
Resident 2's call device was tied to her right-side rail and the call device was hanging below her bed frame.
During an interview with Resident 2, Resident 2 stated she did not know where her call device was, she
would rather stay in bed instead of trying to reach out for her call device, Resident 2 stated she was afraid
of fall. During a concurrent observation in Resident 2's room and interview on 8/12/2025 at 10:25 AM with
CNA 1, CNA 1 stated Resident 2's call device was supposed to be within Resident 2 reach near her hands
area, so the resident can receive the care and services she needs timely and to ensure her safety. During
an interview on 8/12/2025 at 10:50 AM with Registered Nurse Supervisor (RNS), RNS stated the call light
was supposed to be placed within Resident 2's reach for easy access so that residents can get their
services in a timely manner and for safety monitoring. During an interview on 8/12/2025 at 10:55 AM with
Director of Nurses (DON), DON stated the call light was supposed to be placed within Resident 2's reach
for easy access, and the call light is to ensure timely responses to the
Residents Affected - Few
(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:
555338
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
555338
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brighton Care Center
1836 N. Fair Oaks Ave
Pasadena, CA 91103
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)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
resident's requests, needs, and for safety monitoring.During a review of the facility's Policy and Procedure
titled, Answering the Call Light, revised September 2022, indicated, the purpose of this procedure is to
ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the
resident when in bed, from the toilet, from the shower or bathing facility and from the floor.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555338
If continuation sheet
Page 2 of 2