Health inspection·March 11, 2025

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 call light device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach. consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was within reach for two of three sampled residents (Resident 2 and 3). Residents Affected - Few This failure had the potential to result in a delay in care and not receiving assistance timely. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 2/2/2017 with diagnoses that included unspecified (unconfirmed) Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities), essential hypertension (HTN-high blood pressure) and cognitive communication deficit (difficulty communicating due to a disruption in cognitive processes like attention, memory, and reasoning, rather than a primary language or speech problem). During a review of Resident 2 ' s History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/15/2023, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2024, the MDS indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 2 needed moderate assistance from staff for toileting, dressing and personal hygiene. During a review of Resident 2 ' s Care Plan about self-care deficit (when someone has trouble performing daily tasks related to health and well-being), created on 5/29/2018 and last revised on 3/10/2025, the Care Plan indicated an intervention that call light will be within reach and attend needs promptly. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 9/8/2021 with diagnoses that included chronic obstructive pulmonary disease (COPD-chronic lung disease causing difficulty in breathing), muscle weakness and Alzheimer ' s Disease. During a review of Resident 3 ' s H&P, dated 1/28/2025, the H&P indicated Resident 3 did not have Page 1 of 2 555690 555690 03/11/2025 Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

F 0558 the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decisions was severely impaired. The MDS indicated Resident 3 was dependent to staff for toileting, showering and transferring. Residents Affected - Few During a review of Resident 3 ' s Care Plan about self-care deficit, created on 9/8/2021 and last revised on 2/5/2025, the Care Plan indicated an intervention that call light will be within reach and attend needs promptly. During an observation on 3/11/2025 at 8:54 a.m., inside Resident 2 ' s room, observed Resident 2 ' s call light on the floor by the right side of the bed above Resident 2 ' s head. During an observation on 3/11/2025 at 8:55 a.m., in Resident 3 ' s bedside, observed Resident 3 ' s call light on the floor by the right side of the bed tangled with Resident 4 ' s call light. During an observation on 3/11/2025 at 8:59 a.m., outside of Resident 3 ' s room, observed Certified Nursing Assistant 1 (CNA 1) went inside Resident 3 ' s room and came out with Resident 3 ' s food tray. During a concurrent observation and interview on 3/11/2025 at 9:01 a.m., with Restorative Nursing Assistant 1 (RNA 1), at Resident 3 ' s bedside, Resident 3 ' s call light was on the floor. RNA 1 stated Resident 3 and Resident 4 ' s call light were tangled with each other and was on the floor. RNA 1 stated Resident 4 was outside the room and Resident 3 ' s call light was not within Resident 3 ' s reach. During an interview on 3/11/2025 at 9:02 a.m., CNA 1 stated she (CNA 1) went inside Resident 3 ' s room and picked up Resident 3 ' s the food tray. CNA 1 stated she (CNA 1) did not notice that the call light was on the floor. CNA 1 stated she (CNA 1) should have looked around the bed and made sure call light was within Resident 3 ' s reach. During an interview on 3/11/2025 at 10:41 a.m., the Director of Nursing (DON) stated facility failed to ensure call light was within Resident 2 and Resident 3 ' s reach. The DON stated staff should make sure call light was within reach of each residents. The DON stated call light was a device to help residents call for assistance if residents need something. The DON stated if call light are not within reach, resident cannot call for assistance and residents needs would possibly be delayed. During a concurrent interview and record review on 3/11/2025 at 10:51 a.m., with the DON, the facility ' s policy and procedure (P&P) titled, Call System, Residents, dated 9/2022 and last reviewed on 1/29/2025, was reviewed. The P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his or her bed, from toileting or bathing facilities and from the floor. The DON stated the facility's policy was to have the call light within resident reach. 555690 Page 2 of 2