Health inspection·September 4, 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 ensure an allegation of abuse was reported for one of three sampled residents (Resident 1), when Resident 1 reported that a resident (Resident 2) pulled his right arm and touched his right leg multiple times. This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to investigate the allegation of abuse in a timely manner and had the potential for information and recollection of the event(s) to be possibly lost. Findings: During a review of Resident 2's admission Record (Face Sheet) Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including picks disease (a gradual deterioration of nerve cells leading to changes in behavior and social appropriateness), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 6/30/2025, the MDS indicated Resident 2's cognition was moderately impaired. During a review of Resident 2's Nursing Progress Notes dated 9/1/2025 and timed at 10:22 a.m., the Nursing Progress Notes indicated Resident 2 unintentionally touched his roommate's (Resident 1) legs and arms. During an interview on 9/3/2024 at 9:13 a.m., Resident 1 stated Resident 2 was his roommate and on 9/1/2025 Resident 2 walked to his bedside, pulled his right arm, and touched his right leg multiple times. Resident 1 stated he did not like Resident 2 touching him and he was afraid when it happened. Resident 1 stated he yelled for help, but no one came. Resident 2 stated he reported the incident to his assigned Certified Nurse Assistant (CNA) 2 during the 7 a.m. to 3 p.m. shift (9/1/2025). During a telephone interview on 9/3/2025 at 10:45 a.m., CNA 2 stated on 9/1/2025 when he started his shift (7 a.m. to 3 p.m. exact time unknown) Resident 1 reported to him that Resident 2 touched his right arm and right leg many times. CNA 2 stated he reported Resident 1's complaint to Registered Nurse (RN) 1 because it was his duty to report something like this because it could be abuse. During an interview on 9/4/2025 at 7:30 a.m., RN 1 stated Resident 2 reported to her that he did not want Resident 2 wandering around because he was afraid his arm would be pulled again. RN 1 stated she reported the incident to her abuse coordinator and there was a meeting, and a grievance was filed. During an interview on 9/4/2025 at 9:04 a.m., the Administrator (ADM), stated there was a meeting held with staff to discuss Resident 1's complaint and it was determined it was not an allegation of abuse, so he treated it as a grievance. The ADM stated he did not investigate Resident 1's complaint for possible abuse and did not report it to CDPH because he did not believe it was an allegation of abuse. During an interview on 9/4/2025 at 10:57 a.m., the Director of Nursing (DON) stated if a resident continuously touched a resident, we should report the suspected abuse to CDPH. During a review of the facility's Policy and Procedure (P&P), titled, Abuse and Neglect - Clinical Protocol revised 3/2018, the P&P indicated management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with Page 1 of 2 055364 055364 09/04/2025 Long Beach Healthcare Center 3401 Cedar Avenue Long Beach, CA 90807

F 0609 applicable laws and regulations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055364 Page 2 of 2