Health inspection·August 5, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for four of four sampled residents, who had orders for an electrocardiogram ([EKG/ ECG] a test that measures the electrical activity of the heart), and/or who had a change of condition (COC), that the EKG results and the COC were reported to the physician(s) in a timely manner. The facility failed to: 1. Notify the physician when Resident 2 reported lightheadedness, weakness and feeling dizzy when ambulating to the bathroom on 6/20/2025. 2. Notify the physician(s) of the results of EKGs conducted for Resident 1, Resident 3 and Resident 4. These deficient practices resulted in: 1. Resident 2 being assessed with an altered level of consciousness ([ALOC] a change in a person's awareness and responsiveness to their environment, compared to their normal state), bradycardia (a slow HR , reference range 60-100 bpm), hypotension (low blood pressure, below 90/60 mmHg), bradypnea (slow breathing, below 12 breaths per minute) and a critically high Potassium (a metallic element that is important in body functions such as regulation of blood pressure [B/P] and of water content in the cells, transmission of nerve impulses, digestion, muscle contraction, and heartbeat) level of 7.3 milliequivalents ([mEq] a unit of measurement)/per liter ([L] a unit of measurement) (reference range 3.5 to 5.2 mEq/L) on 6/22/2025. Resident 2 was transferred to a General Acute Care Hospital (GACH) on 6/22/2025 where he was admitted to the Intensive Care Unit ([ICU] a specialized section of a hospital that provides critical care to patients with life-threatening illnesses or injuries) and STAT (immediately or without delay) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) was conducted. 2. Resident 1's physician was not aware of Resident 1's EKG results for two days after the EKG was conducted and Resident 3 and Resident 4's physician were not aware of Resident 3 and Resident 4's EKG results for over two months after their EKGs were conducted. Cardiology consultations for follow up related to Resident 3 and Resident 4's EKG results were ordered on 7/13/2025. These deficient practices had the potential for Resident 1, 2, 3 and 4 to suffer detrimental consequences related to their heart including death. 1. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and diabetic chronic kidney disease ([CKD] a serious complication of diabetes that occurs when high blood sugar (b/s) levels damage the kidneys' filtering system). During a review of Resident 2's Minimum Date Set ([MDS] a resident assessment tool) dated 7/15/2025, the MDS indicated Resident 2's cognition (the mental processes involved in acquiring knowledge and understanding) was intact. During a review of Resident 2's untitled Care Plan dated 5/26/2025, the Care Plan indicated Resident 2 had anemia (a condition where the body does not have enough healthy red blood cells) and was at risk for weakness, fatigue (a feeling of tiredness, exhaustion, or lack of energy that can make it difficult to perform daily activities) and Page 1 of 8 055364 055364 08/05/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dizziness. The goal of this care plan was to minimize the signs and symptoms (s/s) of complications related to anemia. The Care Plan's interventions included monitoring Resident 2 for s/s of anemia including dizziness, syncope (a temporary loss of consciousness and muscle control, commonly known as fainting), and weakness, and to report to the physician as needed. During a review of Resident 2's untitled Care Plan dated 5/26/2025, the Care Plan indicated Resident 2 was on diuretic therapy (a treatment that helps the body eliminate excess fluid through the urine often involving water pills) related to hypertension ([HTN] high blood pressure). The goal of this Care Plan was for Resident 2 to be free from discomfort or adverse reactions related to diuretic use for three months. The Care Plan's interventions included monitoring Resident 2 and observing for possible side effects such as dizziness, fatigue, and an increased risk for falls, and reporting to physician. During a review of Resident 2's Untitled Care Plan dated 2/11/2025, the Care Plan indicated Resident 2 had DM. The goal of the Care Plan was to minimize Resident 2's risk for complications related to DM. The Care Plan's interventions included monitoring/documenting/reporting as needed s/s of hyperglycemia (increased b/s) including increase in thirst, headaches, trouble concentrating, blurred vision, frequent urination, fatigue, and weight loss and s/s of hypoglycemia (low b/s) including sweating, tremors (shaking), increased heart rate (HR), pallor (pale skin), nervousness, confusion, slurred speech, lack of coordination, and a staggering gait During a review of Resident 2's Nursing Progress Note dated 6/20/2025 and timed at 3:49 p.m., the Nursing Progress Note indicated Resident 2 experienced an episode of lightheadedness and weakness while using the restroom, verbalizing, I feel dizzy and weak while refusing prescribed medication offered to him because he was concerned the medication might worsen his symptoms. Continued review of Resident's Nursing Progress Note indicated Resident 2's report of lightheadedness, dizziness and weakness were not reported to Resident 2's physician. During a review of Resident 2's Change of Condition (COC) form dated 6/22/2025 and timed at 1:40 p.m., the COC form indicated Resident 2 had three episodes of loose stool, felt weak and requested to have labs (laboratory tests) drawn. The COC form indicated Resident 2's physician ordered a complete blood count ([CBC] a blood test that measures parts of the blood), a comprehensive metabolic panel ([CMP] a blood test that measures a variety of substances in the blood), and a urinalysis ([UA] test that analyzes the urine's chemical contents and the types and amounts of cells it contains) During a review of Resident 2's Physician's Order dated 6/22/2025, the Physician's Order indicated obtaining a CBC, CMP, and UA for Resident 2. During a review of Resident 2's Nursing Progress Note dated 6/22/2025 and timed at 3:46 p.m., the Nursing Progress Note indicated Resident 2 was withdrawn (socially detached and unresponsive) and reported he felt weak. During a review of Resident 2's Nursing Progress Note dated 6/22/2025 and timed at 11:20 p.m., the Nursing Progress Note indicated Resident 2 appeared to be sleepy and reported he felt weak. During a review of Resident 2's Lab Results Report dated 6/23/2025, the lab results indicated the following: Blood Urea Nitrogen ([BUN] is a waste product that forms in the liver when the body breaks down protein) - 132 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount)/per deciliter ([dl] a unit of measurement) (reference range 6-20 mg/dl) indicating a critical result. A high BUN level suggests issues with kidney function, dehydration or possible heart attack Potassium 7.3 mEq/ L High potassium levels may cause life-threatening cardiac arrhythmias, muscle weakness, or paralysis. Carbon Dioxide (a waste product of metabolism (the chemical reactions in the body's cells that change food into energy), produced when your body breaks down food for energy) - 6 mEq/L (reference range 23-29 mEq/L) indicating a critical result. Continued review of Resident 2's Lab results indicated the laboratory called the facility and relayed the critical lab to Licensed Vocational Nurse (LVN) 2 on 6/23/2025 at 11:22 p.m. During a review of 055364 Page 2 of 8 055364 08/05/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 2's Nursing Progress Note dated 6/24/2025 and timed at 4:45 a.m., the Nursing Progress Noted indicated at 12:02 a.m., Resident 2 was assessed with an ALOC, bradycardia, hypotension, bradypnea, and a critically high potassium level at 7.2 mEq/L. The Nursing Progress Note indicated emergency services were called and Resident 2 was transferred to the GACH. During a review of the Ambulance Record dated 6/23/2025, the Ambulance Record indicated emergency services were called because staff at the facility were unable to wake Resident 2 and Resident 2 was hypotensive and bradycardic. The Ambulance Record indicated Resident 2 was lethargic (lack of energy) with generalized weakness and was slow in answering questions. The Ambulance Record indicated Resident 2's blood pressure (BP) was 82/40 (normal BP 120/80) and his HR was 49 beats per minute (bpm) (reference range 60-100 bpm). During a review of the GACH's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the GACH on 6/24/2025 at 12:24 a.m. During a review of the GACH's History and Physical (H&P) dated 6/24/2025, the H&P indicated Resident 2 was lethargic with a HR of 47 bpm and a BP of 92/41. The H&P indicated Resident 2 had severe hyperkalemia (high potassium), metabolic acidosis (the buildup of acid in the body due to kidney disease or kidney failure) and acute renal failure (a sudden and rapid loss of the kidneys' ability to filter waste and maintain proper fluid and electrolyte balance in the body). The H&P indicated Resident 2 was admitted to the ICU and STAT dialysis was conducted. During an interview on 7/31/2025 at 2:35 p.m., the Clinical Mentor (CM) stated if a resident experiences a change from their usual state, the COC should be reported to the physician. The CM stated when a COC is reported to the physician, the facility staff should document the physician's response/instructions in the resident's medical record. The CM stated failure to report a resident's COC could result in a delay of care and treatment. During an interview on 7/29/2025 at 2:34 p.m., Resident 2 stated ten days before he was transferred to the GACH, he was feeling tired and was not eating well but he thought it was normal because of his diabetes. Resident 2 stated he was told by facility staff to wait for the physician to come and see him, but the physician did not come. During an interview on 7/31/2025 at 3:39 p.m., LVN 1 stated on 6/20/2025 Resident 2 reported he felt weak and was dizzy when he walked to the restroom. LVN 1 stated his report of being weak and dizzy was not normal for Resident 2, so she assessed his vital signs ([v/s] measurements of the basic functions of the body including body temperature, blood pressure, pulse , and breathing rate), which were stable, so she did not notify Resident 2's physician that he (Resident 2) was complaining of feeling weak and dizzy. LVN 1 stated Registered Nurse (RN) 2 also assessed Resident 2 and advised her (LVN 1) to monitor Resident 2 throughout the shift. LVN 1 stated RN 2 did not instruct her to notify Resident 2's physician. During an interview on 7/31/2025 at 4:33p.m., Resident 2's Physician stated lab tests were ordered on 6/22/2025 due to the facility staff reporting Resident 2' s COC of feeling weak. Resident 2's Physician stated he was not aware of Resident 2's COC on 6/20/2022. During a review of the facility's Job Description, titled Charge Nurse the Job Description indicated one of the duties and responsibilities of the charge nurse included coordinating with the resident's physician in the care of the resident including notification upon change of condition. During a review of the facility's Policy and Procedure (P/P) titled Change in a Resident's Condition or Status dated 2/2021, the P/P indicated the nurse will notify the resident's attending physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. 2. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including CKD and DM. During a review of Resident 1's MDS dated 055364 Page 3 of 8 055364 08/05/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [DATE], the MDS indicated Resident 1's cognition was intact. During a review of Resident 1's untitled Care Plan dated 4/15/2023 the Care Plan indicated Resident 1 had gastroesophageal reflux disease ([GERD], a condition where stomach contents flow back into the esophagus, causing irritation and discomfort). The goal of the Care Plan was to minimize the complications related to GERD as manifested by nausea and vomiting, stomach pain, vomiting blood, and tarry stools (black, sticky, and foul smelling bowel movements). The Care Plan's intervention included obtaining and monitoring laboratory/diagnostic work as ordered, report results of the labs/diagnostic work to the physician and follow up as indicated. During a review of Resident 1's Physician's Order dated 6/10/2025, the Physician's Order indicated to conduct a 12 lead EKG (a comprehensive view of the heart's electrical activity from twelve different angles, ensuring a detailed and accurate assessment of cardiac function) due to Resident 1's intermittent chest discomfort. During a review of Resident 1's EKG results dated 6/11/2025 and timed at 7:30 a.m., the EKG indicated a diagnosis of abnormal sinus (an abnormal heart rhythm), low voltage QRS (the electrical signals generated by the heart are weaker than what is typically considered normal), consider pulmonary (lung) disease, possibly anterior myocardial infarction ([MI] heart attack, damage to the front wall of the heart caused by a lack of blood flow) age undetermined, anteroseptal (damage to the front left and right ventricles [regions of the heart muscle]). During an interview on 7/30/2025 at 3:34 p.m., Registered Nurse (RN 1) stated EKG results were usually sent to the physician via text message. RN 1 checked the facility's mobile phone's message history and could not find any message sent to Resident 1's physician regarding Resident 1's EKG results on 6/11/2025, nor could she find documentation in Resident 1's clinical record to indicate Resident 1's physician was notified of Resident 1's EKG results During an interview on 8/8/2025 at 12:39 p.m., Resident 1's Physician stated he reviewed Resident 1's EKG results one to two days after the EKG was conducted and he did not remember how he received the EKG results. 3. During a review of Resident 3's admission Record (Face Sheet), the (Face Sheet), indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls) and the presence of a cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was moderately intact. During a review of Resident 3's untitled Care Plan dated 5/8/2025, the Care Plan indicated Resident 3 had a low battery in his pacemaker. The Care Plan's goals indicated that Resident 3 would have a normal BP, a normal HR and heart rhythm. The Care Plan's interventions included assessing Resident 3's cardiac function and for Resident 3's HR to be above 60 bpm. During a review of Resident 3's Physician's Order dated 5/8/2025, the Physician's Order indicated to conduct an EKG on Resident 3 related to Resident 3's pacemaker. During a review of Resident 3's Nursing Progress Note dated 7/31/2025 and timed at 12:54 p.m. (two months, three weeks and two days after the order for an EKG was placed), the Nursing Progress Note indicated Resident 3's EKG results which were completed in 5/2025 were relayed to Resident 3's physician. During a review of Resident 3's Nursing Progress Note dated 7/31/2025 and timed at 1:15 p.m., the Nursing Progress Note indicated Resident 3's physician ordered a cardiology consultation for follow up with Resident 3's pacemaker. During a review of Resident 3's Physician's Order dated 7/31/2025, the Physician's Order indicated a cardiology consultation for Resident 3 for his pacemaker follow up. During an interview on 7/31/2025 at 1:31 p.m., LVN 3 stated after reviewing Resident 3's clinical record that there was no documentation to indicate the results of Resident 3's EKG was relayed to Resident ‘s physician after it was completed in 5/2025. LVN 3 stated she contacted Resident 3's physician today (7/31/2025) to notify him of Resident 3's EKG results from 5/2025. 4. 055364 Page 4 of 8 055364 08/05/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 4's admission Record (Face Sheet), the (Face Sheet) indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including of atrial fibrillation ([a fib] a common heart rhythm disorder where the upper chambers of the heart beat irregularly and rapidly), and presence of a cardiac pacemaker. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was severely impaired (a significant decline in cognitive abilities, including memory, language, judgment, and executive function, to the point where an individual's daily life is severely impacted and they require substantial assistance). During a review of Resident 4's untitled Care Plan dated 7/8/2018, the Care Plan indicated Resident 4 was at risk for an abnormal HR due to the resident's pacemaker. The goals of the Care Plan included minimizing complications related to the pacemaker and for Resident 4 to remain free from s/s of pacemaker malfunction or failure. The Care Plan's interventions indicated checking Resident 4's pacemaker (heart rate, rhythm, battery check) as indicated by Resident 4's physician. During a review of Resident 4's Physician's Order dated 5/8/2025, the Physician's Order indicated to conduct an EKG for Resident 4 due to his pacemaker. During a review of Resident 4's EKG results dated 5/9/2025 and timed at 8:48 a.m., the EKG indicated abnormal sinus, left axis deviation (the heart's electrical activity is abnormally shifted towards the left side of the chest), low voltage QRS limb (EKG leads), probable 1st degree block (irregular or abnormal HR due to a delay in the electrical signals passing through the chambers of the heart), abnormal QRS-T angle (misalignment between the electrical signals through the chambers of the heart), consider primary T wave abnormality (abnormal conduction of electrical signals in the heart). During a review of Resident 4's Nursing Progress Note dated 7/31/2025 and timed at 12:50 p.m., (two months, three weeks and two days after the order for an EKG was placed), the Nursing Progress Note indicated LVN 3 relayed the EKG results which were conducted in 5/2025 to Resident 4's physician. During a review of Resident 4's Nursing Progress Note dated 7/31/2025 and timed at 1:17 p.m., the Nursing Progress Note indicated Resident 4's physician ordered a cardiology consultation for follow up of Resident 4's pacemaker. During a review of Resident 4's Physician's Order dated 7/31/2025, the Physician's Order indicated a cardiology consultation for Resident 4's pacemaker. During an interview on 7/31/2025 at 1:31 p.m., LVN 3 stated after reviewing Resident 4's clinical record that there was no document to indicate the results of Resident 3's EKG was relayed to Resident 4's physician after the EKG was completed in 5/2025. LVN 3 stated she contacted Resident 4's physician today (7/31/2025) to notify him of Resident 4's EKG results from 5/2025. During an interview on 7/31/2025 at 2:35 p.m., the CM stated all EKG results should be reported to residents' physicians no matter what the results were so the physician can give instructions for care/services without any delays. During a review of the facility's P/P titled Lab and Diagnostic Test ResultsClinical dated 11/2018, the P/P indicated a physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent. The P/P indicated facility staff should document information about when, how, and to whom the information was provided and the response. The P/P indicated the documentation should be done in the progress notes section of the medical record and not on the lab results report, because the test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, and prognosis. 055364 Page 5 of 8 055364 08/05/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) was not verbally abused by Certified Nursing Assistant (CNA) 1, when CNA 1 and Resident 5 got into an argument and CNA 1 used profanity. This deficient practice resulted in Resident 5 being frustrated and upset when during an argument between him and CNA 1, CNA 1 said fuck you.During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including post laminectomy syndrome (a condition where persistent or recurrent pain develops after a laminectomy or other spinal surgery) and depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in previously enjoyable activities). During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool) dated 7/17/2025, the MDS indicated Resident 5's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact, and he required substantial/maximal assistance (helper does more than half the effort) to complete his activities of daily living ([ADLS] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 5's Change of Condition (COC) Evaluation note dated 7/28/2025, the COC note indicated Resident 5 was agitated, did not want the CNAs to touch items on his bedside table, and was shouting and cursing at the CNAs. During a review of Resident 5's Interdisciplinary Team ([IDT] a group of professionals from different fields who work together to achieve a common goal) note dated 7/29/2025, the IDT note indicated Resident 5 had a verbal altercation with CNA 1 resulting in Resident 5 raising his voice and CNA 1 responding in a loud manner. The IDT note indicated Resident 5 had poor impulse control which led to Resident 5's verbal outburst towards staff. During an interview on 7/30/2025 at 9:43 a.m., Resident 5 stated on 7/28/2025 he put on his call light and CNA 3 came to his room to tell him that CNA 1 would come to assist him when he (CNA 1) was available and that upset him (Resident 5). Resident 5 stated, when CNA 1 finally came to his room, they got into an argument, CNA 1 was upset, walked out of the room and said, fuck you. Resident 5 stated the experience of CNA 1 saying fuck you to him (Resident 5) was frustrating and upsetting because he usually got along with CNA 1 and he believed CNA 1 was a good worker until this happened. During a telephone interview on 7/30/2025 at 12:52 p.m., Licensed Vocational Nurse (LVN) 4 stated on 7/28/2025 she was at the middle nursing station (down the hall from Resident 5's room) and heard Resident 5 and CNA 1 yelling at each other using profanity and she heard LVN 5 tell CNA 1 that he should not speak to Resident 5 that way. LVN 4 stated after the argument, CNA 1 was very angry and walked toward the front of the building, he was pacing, and he might have kicked the door before he left the building. During a telephone interview on 7/30/2025 at 1:07 p.m., CNA 2 stated she spoke to CNA 1 after the incident and CNA 1 was upset and said Resident 5 was ungrateful and took advantage of his kindness and he (CNA 1) was feeling abused and angry. During a telephone interview on 7/30/2025 at 1:14 p.m., CNA 1 stated when he went to Resident 5's room on 7/28/2025, Resident 5 was upset and was cursing at him about not coming to his room himself and sending CNA 3 instead. CNA 1 stated that he told Resident 5 to calm down, but he (Resident 5) would not calm down. CNA 1 stated he walked out of Resident 5's room and said, fuck this CNA 1 stated Resident 5 heard him curse and responded, fuck you too. CNA 1 stated he did not react appropriately to Resident 5, he should have walked away. CNA 1 stated the way he responded to Resident 5 was considered a form of verbal abuse. During an interview on 8/1/2025 at 2:04 p.m., the Director of Staff Development (DSD) stated as part of the employee's orientation, they are trained how to act professionally and treat the 055364 Page 6 of 8 055364 08/05/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents with respect and dignity. The DSD stated CNA 1 should have walked away when Resident 5 began yelling at him and politely told him (Resident 5) that he (CNA 1) would come back. During an interview on 8/1/2025 at 2:40 p.m., the Administrator (ADM) stated RN 2 reported to him that Resident 5 and CNA 1 were cursing at each other. The ADM stated CNA 1 should have remembered while he was at work to be professional when interacting with residents. During a review of the facility's Job Description for Certified Nursing Assistants (CNA) dated 9/2020, the Job Description indicated CNAs should ensure all residents are treated fairly, with kindness, dignity, and respect, and their rights are protected at all times. The Job Description indicated skills and abilities a CNA should have include the ability to interact tactfully, effectively, and professionally with other employees, residents, family members, and visitors. During a review of the facility's Policy and Procedure (P/P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention dated 4/2021, the P/P indicated the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 055364 Page 7 of 8 055364 08/05/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

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 assess one of four sampled residents (Resident 1) after Resident 1 complained of chest pain and a electrocardiogram ([EKG/ECG] a test that measures the electrical activity of the heart) was ordered due to chest discomfort. This deficient practice resulted no documentation or knowledge of Resident 1's medical stats and had the potential for a delay in care and treatment.During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including CKD and DM. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognition was intact. During a review of Resident 1's Physician Progress Note dated 6/10/2025, the Physician Progress Note indicated Resident 1 reported that she was experiencing chest pain on her left side which started a few weeks prior, but she could not remember the exact date that it began. The Physician Progress Note indicated a 12-lead EKG (a non-invasive test that measures the heart's electrical activity using 10 electrodes placed on the body) would be conducted due t Resident 1's chest discomfort. During a review of Resident 1's Physician's Order dated 6/10/2025, the Physician's Order indicated to conduct a 12-lead EKG for Resident 1 due to intermittent chest discomfort. During an interview on 7/30/2025 at 3:34 p.m., Registered Nurse (RN) 1 stated she received and carried out the order from Resident 1's physician for the 12-lead EKG but stated she did assess Resident 1 for chest pain/discomfort, and she should have assessed her because the indication for ordering the EKG was chest discomfort. RN 1 stated chest pain/discomfort could have been related to conditions including a heart attack. During an interview on 7/31/2025 at 2:35 p.m., the Clinical Mentor (CM) stated after a change of condition (COC) is reported, residents' should be assessed and a care plan created to have a treatment plan for the residents'. During a phone interview on 8/8/2025 at 12:39 p.m., Resident 1's physician stated Resident 1 complained of chest discomfort and as a result of her complaint he ordered that a EKG be conducted. Resident 1's physician stated nursing should follow the protocol when a resident experiences a COC if that includes monitoring and assessment. During a review of the facility's Job Description titled Registered Nurse (RN) Supervisor dated 9/2020, the Job Description indicated the duties and responsibilities of the RN supervisor included performing assessment functions including identification of changes in resident's physical or psychological condition. During a review of the facility's Policy and Procedure (P/P), titled Change in a Resident's Condition or Status dated 2/2021, the P/P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The P/P indicated the nurse will record in the resident's medical record relative to the changes in the resident's medical/mental conditions or status. Residents Affected - Few 055364 Page 8 of 8