Health inspection·July 31, 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:1. Re-admit one of three sampled residents (Resident 1) to the facility after Resident 1 was evaluated and cleared by the General Acute Care Hospital (GACH) to return to the facility.2. Ensure the facility followed its policy and procedure (P&P), titled Bed Holds which indicated if the resident's hospitalization or therapeutic leave exceeds the bed-hold period of (7) days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility.This deficient practice resulted in Resident 1 being unable to return to the skilled nursing facility (SNF) that has been considered their home, for about 12 months after being deemed appropriate for transfer to the SNF. As a result, Resident 1 was transferred to another SNF, and both the Resident 1 and Family Member (FM) 1 experienced unnecessarily psychosocial harm, including emotional distress and dissatisfaction.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses including psychotic disorder (severe mental illnesses where people lose touch with reality) with hallucinations ( a sensory experience that feels real but is not based on an external stimulus) and major depressive disorder( a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a lack of energy that significantly impact daily life). During a review of Resident 1's History and Physical Examination (H&P), dated [DATE], the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was intact. The MDS indicated Resident 1 required setup assistance (helper sets up or cleans up) with eating, oral hygiene, moderate assistance (helper does less than half the effort to complete the task) with toileting hygiene, personal hygiene, maximal assistance (helper does more than half the effort to complete task) with showering, and dressing. During a review of Resident 1's Order Summary Report, dated [DATE], the Order Summary Report indicated the facility may transfer Resident 1 to a GACH for psych evaluation and bed-hold for seven days. During a review of Resident 1's Notice of Transfer/Discharge, dated [DATE], the Notice of Transfer indicated the facility transferred Resident 1 to the GACH. During a review of Resident 1's Nursing Life Cyle (NLC) at the GACH, dated [DATE], the NLC indicated the physician at the GACH ordered to discharge Resident 1 back to the facility on [DATE]. During a review of Resident 1's Discharge Planning note at the GACH, dated [DATE], at 3:07 p.m., the Discharge Planning note indicated, Director of Community Liaison (DCL) 1 at the facility informed the Discharge Care Planner (DCP) 1 at GACH that the facility did not have a bed available for the patient but they will refer to a sister facility who can accommodate Resident 1 until a bed becomes available. The Discharge Planning note indicated, DCP1 spoke to Resident 1's family (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055387 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewater Skilled Nursing Center 2625 East Fourth Street Long Beach, CA 90814 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)