Health inspection·July 28, 2025

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).This 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:A. During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmission was on 6/14/2025 with diagnoses including anxiety disorder (a group of mental health conditions characterized by excessive, persistent, and unrealistic worry and fear about everyday situations), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage).During a review of Resident 1's History and Physical (H&P), dated 6/16/2024, the H&P indicated, Resident 1 had the capacity (ability) to understand and make decision.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/21/2025, the MDS indicated Resident 1 required moderate assistance (Helper does less than half the effort) from one staff for bed mobility and transfer.B. During a review of Resident 2's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmission was on 2/10/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), and malignant neoplasm of cecum (cancerous tumor development in the cecum, which is the beginning of the large intestine[colon]).During a review of Resident 2's H&P, dated 4/7/2025, the H&P indicated, Resident 1 had the fluctuating capacity to understand and make decision.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required moderate assistance from one staff for bed mobility and maximal assistance (Helper does more than half the effort) from one staff for transfer.During an interview on 7/28/2025, at 10:55 a.m., with Resident 1 in the activity room, Resident 1 stated, she was talking with another resident in a hallway near the smoking area and dining room regarding her upcoming wedding on 7/12/2025 around dinner time, and Resident 2 bumped into her wheelchair. Resident 1 stated, Resident 2 did not apologize, and they ended up having a big argument and Resident 2 slapped her left side of face. Resident 1 stated, she reported to the nurse who came to separate them regarding the incident because she did not want Resident 2 to hit her again.During an interview on 7/28/2025, at 11:20 a.m., with Resident 2 in her room, Resident 2 stated, she did not recall the incident. Resident 2 stated, she did not do anything.During an interview on 7/28/2025, at 12:35 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated, she heard about the incident on 7/12/2025 between Resident 1 and Resident 2. CNA 1 stated, Licensed Vocation Nurse (LVN) 1 and Registered Nurse Supervisor (RNS)1 did not report the incident in a timely manner, and they got suspended. CNA 1 Page 1 of 3 055364 055364 07/28/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, alleged abuse should be reported right away because all healthcare workers are mandatory reporters for abuse.During a concurrent interview and record review on 7/28/2025, at 12:55 p.m., with RNS 2, Resident 1's Change in Condition Evaluation, dated 7/12/2025 was reviewed. The Change in Condition Evaluation indicated, Resident 1 stated, another resident came by and hit on the left side of the head, and the primary physician was notified. RNS 2 stated, she recalled that LVN 1 told her that RNS 1 was fully aware of the situation and told her there was nothing else to do further. RNS 2 stated, LVN 1 told her that she should have reported to the Administrator herself. RNS 2 stated, RNS 1 told her that he did not think it was serious since Resident 1 did not have visible injuries. RNS 2 stated, LVN 1 and RNS 1 should have reported alleged physical abuse within two hours of occurrence to Abuse Coordinator (Administrator), State Agency, Ombudsman, and local police per abuse policy.During a telephone interview on 7/28/2025, at 3:10 p.m., with CNA 2, CNA 2 stated, he was at the dining room at the time of incident, and he heard someone yelling for help. CNA 2 stated, he went to hallway and witnessed Resident 1, and Resident 2 were yelling at each other and another resident was holding Resident 1. CNA 2 stated, RNS 1 came a few minutes later, and he reported to RNS 1 what he witnessed. CNA 2 stated, he reported the incident to LVN 1 as well. CNA 2 stated, he thought they would report to proper authorities because he was assisting residents in the dining room, but he found out that they did not report. CNA 2 stated, staff are mandatory reporters, and this incident should have been reported within two hours of occurrence.During an interview on 7/28/2025, at 3:45 p.m., with Administrator (ADM), ADM stated, RNS 1 and LVN 1 admitted that they should have reported alleged abuse within two hours of occurrence, but they did not. The ADM stated, the facility has taken this incident very seriously and had made a decision to terminate both employees. The ADM stated, there was a witness for this altercation and Resident 1 reported it to the staff. The ADM stated, unfortunately LVN 1 and RNS 1 did not do their due diligence. The ADM stated, this incident was noted during the daily change in condition evaluation audit by other staff the next day on 7/13/2025. The ADM stated, he filed the report to all authorities as soon as he found out, but it was already late. The ADM stated, all abuse allegations should be reported to proper authorities within two hours per policy. The ADM stated, delays in reporting and investigations could lead to continuation of abuse situations and inability to protect the residents from repeated abuse situations.During a review of the RNS 1's Interview Statement, dated 7/13/2025, the Interview Statement indicated, RNS 1 expressed doubt that Resident 2 was capable of inflicting harm, but he acknowledged that he should have reported the incident immediately.During a review of the LVN 1's Interview Statement, dated 7/13/2025, the Interview Statement indicated, LVN 1 stated she thought RNS 1 was responsible for reporting it.During a review of the facility's Policy and Procedure(P&P)titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2021, the P&P indicated, Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or the theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Adult protective services (where state law provides jurisdiction in long-term care); Law enforcement 055364 Page 2 of 3 055364 07/28/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

F 0609 Level of Harm - Minimal harm or potential for actual harm officials; The resident's attending physician; and the facility medical director. 3. Immediately is defined as Within two hours of an allegation involving abuse or result in serious bodily injury; or Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Residents Affected - Few 055364 Page 3 of 3