Health inspection·March 18, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate monitoring of targeted behaviors for the use of psychotropic medications was documented and psychiatry (medical specialty that diagnose, prevent, and teat mental health conditions) was notified when one of four sample residents (Resident 3) refused to take their medications. Residents Affected - Few This deficient practice had the potential to result in delayed provision of necessary care and services. During a review of Resident 3 ' s admission record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) [bipolar type]), violent behavior, and delusional (mental health condition in which a person cannot distinguish what is real and imagined). During a review of Resident 3 ' s History and Physical (H&P) dated 12/28/2024 the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 3 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/14/2025 the MDS indicated Resident 3 ' s cognitive skills were intact. The MDS indicated Resident 3 required set up on majority of the Activities of Daily Living (ADL: eating, oral/toilet/personal hygiene) and required supervision for bathing, shower transfer, and dressing the lower body. During a record review of the Order Summary (Physician orders) dated 3/7/2025, the physician order indicated Depakote (Divalproex Sodium: medication used to treat bipolar disorder) Extended Release (ER) oral tablet 24-hour 500 milligram (mg: unit of mass); give one tablet by mouth three times a day for schizophrenia m/b sudden mood change from happy to anger outburst with an active date 12/27/2024. Another order indicated to monitor behavior: episodes of schizophrenia (a mental illness that causes a break from reality) manifested by (m/b) sudden mood change form happy to anger outburst (Depakote). Indicate the number of behavior occurrences followed by the Nonpharmacological intervention (NPI) number .if no behaviors, select not applicable for NPI then Yes or No for effectiveness with an active date of 12/27/2024. The Order Summary inciated an order for Invega Sustenna (Paliperidone Palmitate: antipsychotic injection for schizoaffective disorder) Intramuscular (shot of medicine into muscle) Suspension prefilled syringe 156 mg/milliliter (mL: unit of liquid); inject one (1) mL intramuscularly one time a day every 30 day(s) for schizophrenia m/b refusing meds and aggressive behavior. During a review of the psychiatric follow up (f/u) note dated 1/8/2025 and 2/11/2025 indicated the Page 1 of 5 055077 055077 03/18/2025 Coral Cove Post Acute 1730 Grand Ave Long Beach, CA 90804

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff should report any unwanted behavior and continue monitoring the patient closely for safety. The plan indicated to continue current medications (Invega Sustenna every 30 days and Depakote 500mg 3 times a day) and observe deterioration in function. During a review of a COC dated 2/8/25 at 2:28 p.m., the COC indicated Resident 3 had an episode of inappropriate behavior m/b word calling on staff and acting out. Recommended to monitor behavior and notify medical doctor (md) if it gets worse. During a record review of the Medication Administration Record (MAR: electronic administration of medication record) dated 2/1/2025 - 2/28/2025, the MAR indicated Resident 3 refused Invega Sustenna on 2/26/2025 and has been refusing the Depakote ER 500mg majority of the month (Resident 3 has taken the medication 11 times). The MAR indicated Resident 3 had episodes of schizophrenia m/b sudden mood from happy to anger four (4) times throughout the whole month. During a record review of the MAR dated 3/1/2025 - 3/31/2025, the MAR indicated the number of episodes Resident 3 had for schizophrenia m/b sudden mood change from happy to anger outburst is documented as X on 3/1/2025, 3/4/2024 day (7:00a.m. to 3:00p.m. shift) and night (11:00p.m. to 7:00a.m.) shift, 3/5/2025 day and night shift, and on 3/6/2025 during day and night shift. The MAR indicated Resident 3 had zero (0) episodes during the evening (3:00p.m. to 11:00p.m.) shift. The MAR indicated Resident 3 ' s episodes of schizophrenia m/b refusing meds were documented as X on 3/1/2025 day shift, 3/4/2025 day and night shift, 3/5/2025 day and night shift, and 3/6/2025 day and night shift. The MAR indicated Resident 3 had 3 episodes on 3/2/2025 during the day and 3 episodes on 3/4/2025 during the evening shift. During a record review of a Change of Condition (COC) dated 3/6/2025 at 6:26 p.m., the COC indicated Resident 3 was verbally aggressive. Resident 3 went to the patio to smoke and was yelling and cursing at another resident resulting in the other resident pushing Resident 3 and falling to the ground. During a concurrent interview and record review on 3/19/2025 at 1:11p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated the progress notes dated 2/22/2024, 2/23/25, and 2/24/2025 indicated Resident 3 has been refusing to take her medications almost every day. RNS 1 stated on 2/24/2025, the progress note indicated Resident 3 refused labs, however there was no documentation that the doctor was notified for the lab draw refusal. RNS 1 stated on 2/25/2025, the progress note indicated Resident 3 refused medications and to be monitored for refusing labs, and on 2/26/25, there was no documentation that the doctor was notified Resident 3 refused the medication. RNS 1 stated the doctor should be notified as the medications that are being refused is for her behavior and the resident would start to exhibit behaviors. RNS 1 stated the psychiatrist should also be notified that the resident is not taking their medication. RNS 1 stated the last time the doctor was notified regarding medication refusal for Resident 3 was 2/21/2025 with no new orders given at that time. During a concurrent interview and record review on 3/19/2025 at 1:22p.m. with RNS 1, RNS 1 stated on the MAR dated 3/1/2024 - 3/31/2025 in the section to monitor for behavior episode of schizophrenia m/b aggressive behavior, some are documented as X. RNS 1 stated if a resident does not have the behavior, it is documented as 0 and not X. RNS 1 stated on 3/6/2025, they should have marked 1 during the evening shift. RNS 1 stated monitoring the behavior is important as the medication may require an adjustment based on the increase or decrease of the behavior. During an interview on 3/19/2025 at 3:45p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 055077 Page 2 of 5 055077 03/18/2025 Coral Cove Post Acute 1730 Grand Ave Long Beach, CA 90804

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident 3 is aggressing when she is asking for cigarettes and will be in the smoking patio all the time. CNA 2 stated Resident 3 becomes agitated when she would try to stop Resident 3 from emptying out the cigarettes ash tray. CNA 2 stated Resident 3 is also aggressive towards other residents. During an interview on 3/20/2025 at 9:48 a.m., with Nurse Practitioner [Psychiatry] (NP 1 [P]), NP 1 [P] stated Resident 3 did not exhibit any behaviors while she spoke with her and was not notified Resident 3 had been refusing her medications by the staff. NP 1 [P] stated if she was informed; she had the responsibility to assess the resident and determine why the resident is refusing the medication. NP 1 [P] stated if the resident has been refusing medications and has bene exhibiting aggressive behavior, the resident will be sent out to the hospital as the resident with the aggressive behavior can hurt and cause issues to other residents or nurses. During an interview on 3/20/2025 at 1:44 p.m., with the Director of Nursing (DON), the DON stated if the resident refused a medication, the doctor and family member would be notified. The DON stated if the resident refused their behavioral medication, the psychiatrist would be notified as they would want to know if the resident is exhibiting any behaviors to identify if the medications need to be adjusted. During a concurrent interview and record review on 3/20/2025 at 3:36p.m. with Assistant Director of Nursing (ADON), the ADON stated the MAR dated 3/1/2025 - 3/32/2025; if the staffs document X as the number of behaviors the resident exhibits, it indicates that the resident is being monitored and is the equivalent of having 0 behaviors. The ADON stated if the resident exhibited the behavior, they would indicate the number of occurances. The ADON stated monitoring wass important to identify if there are any behavioral changes (getting better or worse) and indicated she has not heard Resident 3 yell or scream. During a concurrent interview and record review on 3/20/2025 at 3:43p.m. with ADON, ADON stated on MAR dated 2/1/2025 - 2/28/2025 for the section of Depakote 500mg 3 times a day, the 2 ' s documented indicated Resident 3 has been refusing her medications. The ADON stated if the resident is refusing her medications, notify the doctor, family, and psychiatry. During a review of the facility ' s policy and procedure (P&P) titled, Behavior/Psychoactive Drug Management revised date on 11/2018, the P&P indicated occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks (#) on the medication administration record every shift. During a review of the facility ' s P&P titled, Change of Condition Notification revised date on 4/1/2015, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident ' s condition in a timely manner. The facility will promptly inform the resident, consult with the resident ' s Attending Physician .when the resident endures a significant change in their condition cause by, but not limited to: a significant change in the resident ' s physical, mental or psychosocial status. Change of Condition related to Attending Physician notification is defined when the Attending Physician must be notified when any sudden and marked adverse change in the resident ' s condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination consultation with the Attending Physician and a change in treatment plan 055077 Page 3 of 5 055077 03/18/2025 Coral Cove Post Acute 1730 Grand Ave Long Beach, CA 90804

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a functioning call light and place the call light in a reachable position for two of six sampled residents (Resident 10 and 13). Residents Affected - Few This deficient practice had a potential for a delay in meeting the resident's needs for assistance and can lead to frustration, falls and accidents. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic (not due to accident or injury) hemorrhage (blood vessel in brain breaks and bleed) affecting left dominant side, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle of left lower leg and arm, and cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) communication deficit. During a review of Resident 10's History and Physical (H&P) dated 7/3/2024 the H&P indicated Resident 10 was able to make his or her own medical decisions at this time. During a review of Resident 10's Minimum Data Set ([MDS] a resident assessment tool) dated 1/3/2025 the MDS indicated Resident 10's cognitive skills were intact. The MDS indicated Resident 10 was dependent on bathing and toileting hygiene, required maximal assistance rolling left and right, and required supervision for eating, and performing oral and personal hygiene. The MDS indicated Resident 10 had impairment on one side of the upper (arms/shoulders) and lower (hips/legs) extremities. During a concurrent observation and interview on 3/18/2025 at 4:16 p.m. with Resident 10, Resident 10 stated the call light does not work as he has waited for two hours to receive assistance. Resident 10 stated he was very frustrated. Resident 10's call light was observed to be nonfunctional as there was no response when the call light was pressed. During a concurrent observation and interview on 3/18/2025 at 4:34 p.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated when the light turns on outside above the resident's door, it indicated the call light was working. CNA 3 stated Resident 10's call light was not working. CNA 3 stated Resident 10 yells her name because his call light doesn't work, when he requires assistance. CNA 3 stated the call light not functioning for Resident 10 is not acceptable as all of the residents require a call light and a non-working call light can impact the resident during an emergency. During a concurrent observation and interview on 3/19/2025 at 10:57 a.m., with Resident 10, Resident 10's call light was observed clipped on the right side of the bed closer to the head of the bed and was not able to reach the call light due to a dislocated shoulder on the right side. During a concurrent observation on 3/19/2025 at 11:01 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 observed Resident 10 was unable to reach the call light where it was placed. During an interview on 3/19/2025 at 12:28 p.m., with CNA 4, CNA 4 stated the call light is there so the residents can get a hold of the staff. CNA 4 stated it is important the call light is reachable to prevent and avoid any falls or fractures. 055077 Page 4 of 5 055077 03/18/2025 Coral Cove Post Acute 1730 Grand Ave Long Beach, CA 90804

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including contracture of unspecified joint and left elbow, hemiplegia and hemiparesis following cerebral infarction (blood flow to the brain is blocked affecting left non-dominant side, and generalized muscle weakness. During a review of Resident 13's H&P dated 5/7/2024 the H&P indicated Resident 13 had the capacity to understand and make decisions. During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13's cognitive skills were intact. The MDS indicated Resident 13 required maximal assistance for lower body dressing, required moderate assistance bathing, toileting hygiene, upper dressing, toilet transfer, required supervision for chair/bed-to-chair transfer, and required set up for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 13 had an impairment on one side of the upper extremities and impairments on both of the lower extremities. During a concurrent observation and interview on 3/18/2025 at 4:47p.m. with Resident 13, Resident 13 stated when he presses the call light, no one comes. Resident 13 stated he has waited a couple of hours. Resident 13 stated he does not know where his call light is and was observed to be on the floor. During an interview on 3/19/2025 at 2:10 p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated everyone can answer call lights. RNS 1 stated call lights are there for safety and to meet the residents need. RNS 1 stated without a call light, the resident can fall. RNS 1 stated if the call light is not working, they will notify maintenance. During an interview on 3/20/2025 at 1:17p.m. with the Director of Nursing (DON), the DON stated the call light is for the residents when they need assistance. The DON stated it was important that Residents are able to reach their call lights, because not all residents can get out of bed to go and get what they need. The DON stated Residents (general) need to be able to call for help. During a review of the facility's policy and procedure (P&P) titled, Communication-Call System, effective date 10/9/2024, the P&P indicated the call alert device will be placed within the resident's reach. The facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities. The purse is to ensure the residents have a means of contacting facility staff for assistance. 055077 Page 5 of 5