Health inspection·July 11, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 3) after Resident 3 was transferred to a General Acute Care Hospital (GACH) to evaluate a distended (swollen or enlarged) abdomen with pain on 6/7/2025.This failure resulted in Resident 3 experiencing a prolonged stay at the GACH and frustration from not being able to return the facility which he considered to be his home. Findings: During a review of Resident 3's admission record, the admission record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs) and hydronephrosis (swollen kidneys due to blockage in the urinary tract). During a review of Resident 3's History and Physical (H&P), dated 1/31/2024, the H&P indicated Resident 3 was able to make decisions for activities of daily living. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/7/2025, the MDS indicated Resident 3's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 3 required set-up assistance for eating and oral hygiene, and required supervision for toileting and dressing. During a review of Resident 3's Change of Condition (COC) Evaluation dated 6/7/2025, the COC Evaluation indicated Resident 3 had a bloated and distended abdomen that was hard when touched accompanied by pain on 6/7/2025. The COC Evaluation indicated the medical doctor ordered for Resident 3 to be transferred to the GACH. During an interview on 7/11/2025 at 11:22 a.m., with Resident 3, Resident 3 stated the GACH Case Manager told him the facility does not have an available bed for him to return to. Resident 3 stated he was frustrated and has been waiting to be discharged . Resident 3 stated he wants to return to the facility because it is his home, and it is near his family. During an interview on 7/11/2025 at 2:32 p.m., with the Admissions Coordinator (AC), the AC stated she received a call on 6/26/2025 from the GACH Case Manager (CM) 2 inquiring about Resident 3 returning to the facility. The AC stated she told the GACH CM 2 there were no available male beds at this time. The AC stated this was the only communication she had with the GACH.During a review of Resident 3's GACH Order Summary, the Order Summary indicated Discharge to Skilled Nursing Facility (SNF) was active on 6/27/2025 at 2:17 p.m. During an interview on 7/11/2025 at 11:41 a.m., with the GACH Case Manager (CM) 1, CM1 stated Resident 3 has had an active discharge order since 6/27/2025 and the discharge order was still active as of 7/11/2025. GACH CM 1 stated Resident 3 is waiting for placement to a nursing facility. During a review of Resident 3's GACH Case Management Progress Notes dated 6/28/2025 11:17 a.m., the Progress Notes indicated the GACH contacted the facility and was told the Director of Nursing (DON) is not able to accommodate Resident 3 due to new admissions. During a concurrent interview and record review on 7/11/2025 at 2:48 p.m., with the Director of Nursing (DON), the facility Census and Bed Assignments for 6/10/2025 to 7/11/2025 were reviewed. The Facility Census and Bed Assignment indicated one available male bed from 6/27/2025 - 6/29/2025, two available Page 1 of 3 055077 055077 07/11/2025 Coral Cove Post Acute 1730 Grand Ave Long Beach, CA 90804

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few male beds from 6/30/2025 - 7/1/2025, and one available male bed form 7/2/2025- 7/6/2025. The DON stated there was at least one available male bed from 6/27/2025 to 7/6/2025, 11 consecutive days. The DON stated the facility is the resident's home, and we try to accommodate them back to the facility including when the seven-day bed-hold expires. The DON stated, if the bed was available, the resident should have returned to the facility. During a review of the facility's policy and procedure (P&P), titled Bed Hold, revised July 2017, The P&P indicated, In the event that the resident is in the hospital for more than seven (7) days, meets the standards for skilled nursing care, and is Medi-Cal/Medicaid eligible, the Facility will readmit the resident to his/her previous room or the first available bed in a semi-private room. 055077 Page 2 of 3 055077 07/11/2025 Coral Cove Post Acute 1730 Grand Ave Long Beach, CA 90804

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise a care plan for one of three sampled residents when Resident 2 was readmitted to the General Acute Care Hospital (GACH) on 6/23/2025 after being transferred to the GACH for aggressive behavior on 6/10/2025.This failure resulted in Resident 2 throwing a book at Resident 1 on 6/27/2025. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (damage or disease that affects brain function), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 2's History and Physical (H&P), dated 1/31/2024, the H&P indicated Resident 2 had fluctuating capacity and was able to make decisions for activities of daily living. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 2's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 2 required supervision for eating and oral hygiene, and required moderate assistance for toileting, bathing, and dressing. During a concurrent interview and record review on 7/11/2025 at 12:11 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 2's medical record was reviewed. The MDSC stated Resident 2 was transferred to a General Acute Care Hospital (GACH) on 6/10/2025 for a behavior of yelling and striking out at staff. The MDSC stated on 6/10/2025, Resident 2's care plans were updated to include an intervention of 1:1 supervision as ordered for safety. The MDSC stated Resident 2 was readmitted to the facility on [DATE] but did not require 1:1 supervision because Resident 2 was not aggressive. The MDSC stated Resident 2's behavior care plans were not revised upon readmission on [DATE], but should have been reviewed and revised to provide the appropriate care to the resident. The MDSC stated Resident 2 threw a book at Resident 1 on 6/27/2025. The Psychiatric Follow up Note date 6/27/2025 indicated Resident was observed to be anxious, irritable, emotionally labile, exhibited signs of poor impulse control and unpredictable behavior, with angry outbursts. The Psychiatric Follow up Note indicated a recommendation to transfer Resident 2 to an inpatient psychiatry facility on 7/27/2025 for stabilization. The MDSC stated more frequent resident supervision, such as 1:1 supervision could prevent resident-to-resident altercations. During an interview on 7/11/2025 at 4:01 p.m., with the Director of Nursing (DON), the DON stated care plans need to be updated when residents are readmitted . The DON stated if we don't review and update care plans, there may be a gap or delay of care to residents.During a review of the facility's policy and procedure (P&P), titled Comprehensive Person-Centered Care Planning, revised 8/24/2023, The P&P indicated comprehensive car. 055077 Page 3 of 3