Health inspection·February 9, 2026

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the alleged physical abuse between Resident 1 and Resident 2 to the State Survey Agency (California Department of Public Health -CDPH) within two hours of the occurrence for two of three sample residents (Resident 1 and Resident 2) The failure had potential to result in a delay of an onsite inspection by the CDPH to ensure alleged physical abuse was investigated and lead to a delay in prevention of potential ongoing physical abuse. Findings:During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 1 on 6/6/2025 with diagnoses including type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar-control and poor wound healing), chronic obstructive pulmonary disease (chronic lung disease causing difficulty in breathing), osteoarthritis (progressive disorder of the joints, caused by a gradual loss of cartilage), and schizophrenia (mental illness that is characterized by disturbances in thought).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 1/7/2026, the MDS indicated Resident 1 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) from staff. During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 2 on 10/29/2025 with diagnoses including chronic kidney disease (kidneys lose the ability to clean blood and remove waste), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar-control and poor wound healing), heart disease (blood vessels around the heart are damaged and harder for the heart to pump blood), gout (uric acid builds up and forms crystals in joints causing painful swelling).During a review of Resident 2's History and Physical (H&P), dated 10/31/2025, the H&P indicated Resident 2 had the capacity (ability) to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required moderate assistance (Helper does less than half the effort) from one staff for bed mobility and transfers. During an interview on 2/9/2026 at 9:20 a.m. with Resident 1, Resident 1 stated Resident 2 did not hit his head with a cane. Resident 1 stated he has no concerns with Resident 2.During an interview on 2/9/2026 at 1:45 p.m. with Resident 2, Resident 2 stated Resident 1 was lying on his left side and was coughing with particulates on his face. Resident 2 stated he used the rubber handle of his cane to lift Resident 1's pillow. Resident 2 stated he retracted his cane when Occupational Therapist Technician (COTA) 1 was standing in doorway and alleged he hit Resident 1 on the head with his cane.During a concurrent interview and record review on 2/9/2026 at 11:15 a.m. with Registered Nurse Supervisor (RNS), the RNS stated Licensed Vocational Nurse (LVN) 1 informed her of the physical abuse allegation where Resident 2 hit Resident 1 on the head with a cane. The RNS stated she transferred Resident 1 to another room, removed Resident 2's cane, and notified Resident 1's the physician. During an interview on 2/9/2026 at 1:00 p.m. with LVN 1, LVN 1 stated COTA 1 reported the alleged abuse Page 1 of 2 055077 055077 02/09/2026 Coral Cove Post Acute 1730 Grand Ave Long Beach, CA 90804

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Resident 2 hitting Resident 1 on the head with a cane. LVN 1 stated he assessed both residents and informed the RN Supervisor (RNS). LVN 1 stated RNS relocated Resident 1 to another room and removed Resident 2's cane.During an interview on 2/9/2026 at 1:30 p.m. with the Administrator, the Administrator stated reporting to CDPH, law enforcement, and the Ombudsman must occur immediately, within two hours. The Administrator stated administration conducted their own investigation first and then the RNS faxed the SOC341 (a form used to document information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult) report on 1/26/2026 at 4:34 p.m. to CDPH and the Ombudsman, seven hours after the allegation that Resident 2 hit Resident 1 on the head with a cane.During a record review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 1/1/2026, indicated The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, and send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification: i. Immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury. 055077 Page 2 of 2