Health inspection·January 26, 2024

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was at risk for impaired thought processes manifested by psychosis and persistent mood disorder (psychiatric disorders). The CP indicated the goal was to maintain a current level of cognitive function. The CP interventions were to provide psychosocial support as needed and monitor for any changes in cognitive functions. The CP indicated Resident 64 had the potential for a mood problem related to feeling down and trouble concentrating. The CP interventions were to provide behavior consults as needed. The CP indicated Resident 64 was on psychotropic medications related to schizophrenia and the interventions were to administer medications as ordered. During a review of Resident 64's psychiatric progress note (PN) dated 7/5/2023, the PN indicated Resident 64 had a history of bipolar disorder diagnosed 9/24/2021, anxiety diagnosed 7/18/2021 and schizophrenia disorders (undated). During a review of Resident 64's PASRR Level 1 screening dated 12/22/2023, the Level 1 screening was positive, and it indicated a Level 11(2) screening was required. During a review of Resident 64's PASRR Level 2 screening dated 12/26/2023, the Level 2 screening evaluation indicated a Level 2 was not scheduled because Resident 64 had no serious mental illness. During an interview on 1/24/2023 at 4:20 pm with the MDS coordinator, the MDS coordinator stated she is sure Resident 64 had a psychiatric diagnosis and stated Resident 64 Level 1 PASSR was positive, that required a Level 2 examination. The MDS coordinator stated Resident 64 sees a psychiatrist (prior to entering the facility) who manages her psychiatric medications. During an interview on 1/24/2024 at 4:35 p.m. with the Infection Prevention Nurse (IPN), IPN stated someone called her from the state at the facility for a Level 2 examination for Resident 64 and she told them that Resident 64 was not exhibiting any behaviors like delirium. The IPN stated, they will close the case (state) on Resident 64. The IPN stated if Resident 64 stopped taking her antipsychotic medications, she would exhibit psychiatric symptoms. The IPN stated she is not familiar with the services offered for a Level 2 PASRR. The IPN stated she thinks Resident 64 could benefit from a Level 2 PASRR. During an interview on 1/26/2024 11:47 a.m. with the Director of Nurses (DON), the DON stated a Level 2 PASRR was required for Resident 64 and the reason documented for not doing it, is not true. The DON stated Resident 64 should have had a Level 2 PASRR examination based on her history of a psychiatric diagnosis. B.During a review of Resident 12's admission Record (facesheet) dated 11/15/2019, the facesheet indicated Resident 12 was admitted to the facility with diagnoses of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), depression ( mental health disorder characterized by a persistent depressed mood ) and hypertension (high blood pressure). During a review of Resident 12's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 11/18/2023, the MDS section C indicated Resident 12 was had mild cognitive impairment (the stage between the expected decline in memory and thinking) regarding ADL's. During a review of Resident 12's care plan (CP) revised on 12/2/2023, the CP indicated Resident 12 had the potential for a mood problem related to her psychiatric diagnosis. The CP indicated the goal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 2 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is for Resident 12 was to have improved sleep. The CP indicated interventions were to have behavioral health consults as needed and to monitor for anxiety and depression. The CP revised on 5/23/2023, indicated Resident 12 was taking psychotropic medication related to schizophrenia. The CP interventions indicated to monitor/report/record and side effects from the medication. During a review of Resident 12's physician orders summary (PO) dated January 2024, the PO indicated Resident 12 had an order for a psychiatrist consult as needed. The PO indicated that Resident 12 was taking Zyprexa (an antipsychotic medication that can treat several mental health conditions like schizophrenia) 5mg (unit of measurement) by mouth at bedtime for schizophrenia. During a review of Resident 12's PASRR Level 1 screening dated 12/22/2023, the Level 1 screening was positive, and it indicated a Level 11(2) screening was required. During a review of Resident 12's PASRR Level 2 screening dated 12/26/2023, the Level 2 screening indicated a Level 2 was not scheduled because Resident 12 had no serious mental illness. During an interview on 1/26/2024 at 11:47 a.m. with the Director of Nurses, the DON stated it is the responsibility of the MDS coordinator to make sure the PASRR diagnosis is correct. The DON stated it is important the PASRR is done, and the recommendations are correct to make sure the resident is receiving the right care and is in the right facility setting. The DON stated a resident may require more care because of their psychiatric issues. The DON stated Resident 12 has a psychiatric diagnosis and is on antipsychotic medications. The DON stated, Resident 12's Level 1 evaluation was positive. During a review of the facility policy and procedure (P&P) titled PASSR dated 12/2022, the P&P indicated, it is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the state. The P&P indicated PASRR Level II is a comprehensive evaluation required as a result, of a positive Level I Screen. The P&P indicated a Level II is necessary to confirm the indicated diagnosis noted in the Level I Screen and to determine whether placement or continued stay in a Nursing Facility is appropriate. The P&P indicated Social Services (SS) shall contact the appropriate State Agency (SA) for referral of specialized care and services the resident may require. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 3 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide for one (1) of 19 sampled residents (Resident 29) an ongoing program to support the resident in a choice of activities such as activities, regular room visits. Residents Affected - Few This deficient practice has the potential to cause psychosocial harm and feelings of isolation for Resident 29 and further exacerbations (negative feeling) of depression and anxiety. Findings: During a review of Resident 29's admission Record dated 10/17/2023, the admission Record indicated Resident 29 was admitted to the facility with diagnoses of anxiety (a feeling of worry or nervousness), gallbladder (a small sac-shaped organ that stores digestive fluids) cancer, and gait and mobility abnormalities (unable to walk). During a review of Resident 29's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 11/17/2023, the MDS indicated that resident 29 had completely intact cognition (mental process of thinking and understanding) to make daily decisions for Activities of Daily Living (ADL's toileting, grooming, eating and personal hygiene). During a review of Resident 29's care plan (CP) titled Resident Centered Care dated 11/15/2023, the CP indicated Resident 29 was dependent on staff for activities and social interaction. The CP indicated the goals were for Resident 29 to participate in activities of choice, maintain involvement in cognitive stimulation and social activities as desired. The CP indicated the interventions were that activity staff would continue to monitor and encourage the resident to attend and participate in activities and Resident 29 would be provided reading materials as needed. The CP interventions indicated the staff would provide a program of activities that is of interest to Resident 29 and provide activities as desired. During a concurrent observation and interview on 1/23/2024 at 11:30 a.m. with Resident 29 at the bedside, Resident 29 stated, the facility did not provide activities to her in her room. Resident 29 stated she would like to have activities in her room and doesn't prefer to go to the dining room for activities. During observation at Resident 29's bedside, there were no activities such as book, arts and crafts or crossword puzzles. During a concurrent interview and record review on 1/24/2024 at 11:29 a.m. with the Activity Director (AD), The AD stated activities are done in the room for residents that don't want to come to the dining room for activities. The AD stated all residents are offered activities in their rooms and the schedule is given to the residents daily. The AD stated, they have room to room visits for activities three times a week at 1 p.m. The AD reviewed the activity log dated 1/9/2024 to 1/17/2024 and confirmed Resident 29 was not on the list for in-room activities and had not been seen by activity staff. During an interview on 1/25/2024 at 9:47 a.m. with Resident 29 at the bedside, Resident 29 stated she was not offered any in-room activities all week by staff. Resident 29 stated, she does not like to go to the dining room. Resident 29 stated she would not mind having activities in her room. Resident 29 stated she only watches television every day because that is what is available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 4 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0679 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/26/2024 at 8:47 a.m. with the AD, the AD stated, Resident 29 gets activities in her room. The AD stated the last time Resident 29 was in the dining room was two weeks ago. The AD stated residents should be offered activities every day. The AD stated she has not personally offered Resident 29 any activities from 1/11/2024-1/24/2024 and there was no documentation that Resident 29 was offered any activities from 12/31/2023-1/25/2024. Residents Affected - Few During a concurrent observation and interview on 1/26/2024 at 10:23 a.m. with the AD at Resident 29's bedside, Resident 29 stated she was not offered any activities in her room like coloring, crossword puzzles or books. Resident 29 stated she loves to read books but was not offered any books and no books were observed at her bedside. During an interview on 1/26/2024 at 10:30 a.m. with the AD, the AD stated it is important for residents to have activities for their mental health, to be able to socialize and keep active. The AD stated if Resident 29 is watching television every day, she could get bored. The AD stated, she will take full responsibility to make sure Resident 29 will receive activities going forward. During a review of the facility policy and procedure (P&P) titled Resident Rights revised 12/2022, the P&P indicated schedules of daily activities allow maximum flexibility for residents to exercise choices about what they will do and when they will do it. The P&P indicated Residents' individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, and entertainment are elicited and respected by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 5 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure a safe, hazard free environment as evidenced by topical medication left in a medication cup at the bedside of one of one Residents (Resident 81). This deficient practice placed Resident 81 and other residents of the facility at risk of adverse effects due to misuse of the medication left at the bedside table. Findings: During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (a disease caused by disrupted blood flow to the brain which may cause parts of the brain to die off), hypokalemia (low potassium [essential substance to maintain health] level in the bloodstream), and cognitive (the ability to think and process information) communication deficit. During a review of Resident 81's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/08/2024, the MDS indicated, Resident 81's cognitive skills was moderately impaired. The MDS indicated Resident 81 had Stage 3 pressure ulcers (skin injury due to continuous pressure that has exposed the fat layers beneath which may pose a high risk of infection) that were present upon admission. During a review of Resident 81's untitled care plan dated 1/03/2024, the care plan indicated that Resident 81 was at risk for impaired cognitive function. The care plan's interventions indicated Resident 81 needs supervision and assistance with all decision making. During an observation on 1/23/2024 at 9:32 a.m., Resident 81 was observed lying in the bed and white thick paste was in a medication cup on resident 81's bedside table. During an interview on 1/23/2024 at 10:15 a.m., with Treatment Nurse (TX) 1, TX 1 stated, the white thick topical paste was a medication and she should not have left it at the bedside. TX 1 stated, after each treatment is completed, we need to check all medication and supplies and make sure to discard them before leaving the resident's room. TX1 stated, if nurses leave any topical medication unattended at the bedside, the resident might use it for something other than what it is meant for and it is not safe for the resident. During an interview on 1/25/20223 at 3:46 p.m., with Director of Nursing service (DON), DON stated, topical treatment cream is also considered a topical medication and nurses should not leave any medication unattended at bedside because any resident can have access to it and may lead to adverse effect from the medication. During a review of facility's policy and procedure (P/P) titled, Preparation and General Guidelines, revised 10/2019, the P/P indicated Medications are administered as prescribed in accordance with good nursing practices and only by persons legally authorized to do so. The P/P indicated that the resident is always observed after administration to ensure that the dose was completely ingested. The facility did not provide a policy on Resident Safety or Accidents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 6 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure for dating oxygen tubing and nasal cannula (([NC], a device that deliver extra oxygen through a tube and into the nose) by ensuring the oxygen tubing was maintained weekly for three (3) of 19 sampled residents (Residents 33, 12 and 235) who were receiving oxygen therapy. Residents Affected - Some This deficient practice placed residents at risk of respiratory infections by directly transferring potentially pathogenic (disease causing) organisms through the tubing onto the mucous membranes (moist inner lining of body cavities such as the nose) inside the residents' nasal passages, causing complications associated with oxygen therapy. Findings: A. During an observation on 1/23/2024 at 8:44 a.m. during the initial tour, Resident 33's oxygen nasal tubing that was not labeled or dated and was on Resident 33's bedside table. During a review of Resident 33's admission Record dated 11/29/2017, the admission Record indicated Resident 33 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease ([COPD] a condition involving narrowing of the airways and difficulty or discomfort in breathing), schizophrenia (a serious mental condition involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion) and sepsis (infection in the bloodstream). During a review of Resident 33's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 12/22/2023, the MDS indicated Resident 33 had severe cognitive (ability to remember, learn, concentrate and [NAME] decisions) impairment. During a review of Resident 33's physician orders dated 1/22/2024, the Physician's orders indicated Resident 33 had an order for oxygen at two (2) lpm ([lpm] a unit in the category of Volume flow rate) for shortness of breath continuously. During a concurrent observation and interview on 1/23/2024 at 11:00 a.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated, Resident 33's nasal cannula tubing was changed on 1/19/2024 and the tubing should be dated to indicate the date. LVN 3 confirmed Resident 33's oxygen tubing was not dated. B. During an observation on 1/23/2024 at 12:54 p.m. in the dining room Resident 12 was observed sitting in a wheelchair wearing oxygen nasal tubing that was not dated. During a review of Resident 12's admission Record dated 11/15/2019, the facesheet indicated Resident 12 was admitted to the facility with diagnoses of schizophrenia, depression ( mental health disorder characterized by a persistent depressed mood ) and hypertension (high blood pressure). During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 had mild cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 7 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 12's physician orders dated 1/4/2024, the physician's orders indicated Resident 12 had an order for oxygen 2 liters per minute for oxygen. During a concurrent observation and interview on 1/23/2024 at 12:55 p.m. with LVN 3, LVN 3 stated, Resident 12's oxygen tubing was not dated, but it should be. LVN 3 stated, it is important to date the oxygen tubing so the staff will know if it was clean and to follow infection control practices. LVN 3 stated she will remove Resident 12's oxygen tubing and replace it because she doesn't know how long the resident has been using it, since it is not dated. (C) During a review of Resident 235's admission Record, the admission Record indicated Resident 235 was admitted to the facility on [DATE], with diagnoses including emphysema (gradual damage of lung tissue), transient ischemic attack (temporary period of symptoms such as extreme weakness caused by blockage of blood flow), and muscle weakness. During a review of Resident 235's history and physical, the history and physical indicated, Resident 235 has the capacity to understand and make decisions. During a review of Resident 235's MDS, dated [DATE], the MDS indicated, Resident 235's cognitive skills was moderately impaired. During a review of Resident 235's order summary report dated 1/4/2024, the record indicated, Resident 235 had a physician's order to apply oxygen via nasal cannula at 3 LPM continuous to keep saturation (a clinical measure of the amount of oxygen in patient's blood) at or above 90% every shift. During a review of Resident 235's care plan dated 1/04/2024, the care plan indicated that Resident 235 had oxygen therapy related to hypoxemia (low levels of oxygen in your blood), and emphysema. The care plan's interventions indicated oxygen settings: apply oxygen via NC at 3 LPM continuous to keep saturation at or above 90%. During a concurrent observation and interview on 1/23/2024 at 11:26 a.m., with LVN 1, Resident 235's oxygen tubing was undated and was laying on another resident's bed. LVN 1 stated, the oxygen tubing should be placed in bag when not in use. LVN 1 stated, there is no date and label on the oxygen tubing. LVN 1 stated, charge nurses are responsible for checking if a resident's oxygen tubing is dated and labeled because the NC should be changed every 7 days. LVN 1 stated, nurses should provide bags for cannulas so they can use the bag to keep the NC clean when residents are not in the room. During an interview on 1/25/2024 at 3:45 p.m. with the Infection Preventionist (IP), the IP stated all oxygen tubing should be dated so the staff will know when it was placed on the resident. The IP stated if the oxygen tubing is not changed, the resident could develop a respiratory infection. The IP stated it is the responsibility of the licensed nurse to change the oxygen tubing every 7 days and date the oxygen tubing. During an interview on 1/26/2024 at 11:26 a.m., with Director of Nursing Services (DON), DON stated, if oxygen tubing nasal cannula are not in use, they should place it in plastic bag belonged to the resident. If the oxygen tubing NC was laying on other resident's bed, it is contaminated, and we will need to throw it away because it can potentially lead to respiratory infection. All oxygen tubing should be labeled and dated with started or changed date of the oxygen tubing and we change the oxygen tubing when it is contaminated or every 7 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 8 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm During a review of the facility policy and procedure (P&P) titled Use of Oxygen dated 5/2021, the P&P indicated oxygen cannula or mask will be changed at least every 7 days, as well as the disposable humidifier. The P&P indicated tubing, masks, humidifiers, and other disposables used for Oxygen administration will be dated in an identifiable fashion. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 9 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain safe proper storage of medications, document medications after administration and secure controlled medications by: 1. Failing to ensure the antibiotic medication count sheet for two (2) of two residents (Resident 34 and Resident 44) was signed after medication administration. 2. Failing to ensure the emergency kit #87([E-kit] a small quantity of medications that can be dispensed when pharmacy services are not available) was sealed and locked in the medication storage room. These deficient practices had the potential for medication dispensing errors, theft or diversion for controlled medications and placed staff and residents at risk for unsafe medication administration. Findings: 1. During a concurrent observation and record review on 1/25/2024 at 12:12 pm, with Licensed Vocational Nurse (LVN 4), of medication cart number two, LVN 4 stated, she administered antibiotics (medications used to treat infections) to Resident 34 and Resident 44. LVN 4 stated, she forgot to sign the antibiotic medication count sheet for both residents. During a review of Resident 34's admission Record dated 12/20/2019, the admission Record indicated Resident 34 was admitted to the facility with diagnoses of diabetes (a disease in which the body's ability to process sugar for energy is impaired, resulting in elevated levels of glucose in the blood and urine), seizures (a burst of uncontrolled electrical activity between brain cells) and hypothyroidism (a condition where the body does not release enough substance to regulate the functioning of the body). During a review of Resident 34's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 11/23/2023, the MDS indicated Resident 34 decision making was severely cognitively impaired (difficulty thinking and reasoning). During a review of Resident 34's physician's orders dated 3/11/2023, the physician's orders indicated Resident 34 had a medication order for Valganciclovir (medication used to treat infections caused by viruses) 450 milligrams (mg a unit of measure of weight) by mouth every Monday and Thursday. 2.During a review of Resident 44's admission Record dated 1/17/2020, the admission Record indicated Resident 44 was admitted to the facility with diagnoses of Alzheimer's disease (progressive mental deterioration), hypertension (high blood pressure) and anxiety (a feeling of worry, nervousness, or unease). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 10 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 44's MDS dated [DATE], the MDS indicated Resident 44's ability to make decisions of daily living was severely impaired. During a review of Resident 44's Physician Order's dated 1/20/2024, the Physican orders indicated Resident 44 had an order for Amoxicillin-Clavulanate tablet 875mg-125mg every 12 hours. Residents Affected - Some During an interview on 1/25/2024 at 12:20 p.m., with LVN 4, LVN 4 stated she was supposed to sign the antibiotic medication count sheet as soon as the medication was administered. LVN 4 stated, it was important to document a signature to be accountable for the medications and avoid giving duplicate (double) doses. C. During an observation on 1/25/2024 at 12:40 p.m. of the medication storage room, it was observed that the medication E-Kit #87 lock was unsealed (broken) and left open with medications exposed for use without authorization or a physician's order. During a concurrent observation and interview on 1/25/2024 at 12:40 p.m. in the medication storage room with the Registered Nurse Supervisor (RNS 1), RNS 1 stated the E-kit was left unlocked for two days from 1/23/2024 to 1/25/2024. RNS 1 stated the E-kit should always be locked to prevent staff from removing medications at anytime without a physician order and to make sure the licensed staff is always accountable for the medications. RNS 1 stated it was important to keep the E-kit always locked to prevent misuse of medications. During an interview on 1/26/2024 at 11:47 a.m. with the Director of Nurses (DON), the DON stated the E-kit should be always locked in the facility. The DON stated it is the responsibility of the RNS to make sure the E-kit is always locked. The DON stated it is important to have the E-kit locked, so the facility can be accountable for controlled medications because it can affect the residents receiving their medications. During a review of the facility policy and procedure (P&P) titled Medication Storage in the facility dated 8/2019, the P&P indicated medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. The P&P indicated the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During a review of the facility P&P titled Preparation and Storage dated 10/2019, the P&P indicated the individual who administers the medication dose records the administration on the resident's MAR after the medication pass is completed. The P&P indicated at the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. During a review of the facility P&P titled Medication Ordering and Receiving from the Pharmacy dated 9/2019, the P&P indicated when an emergency or state dose of a medication is needed, the nurse unlocks the container and removes the required medication. The P&P indicated after removing the medication, complete the emergency e-kit slip and re-seal the emergency supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 11 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide two of 10 sampled residents (Resident 59 and Resident 4) a mechanical soft diet (a diet that was designed for people who have trouble chewing and swallowing) with chopped food items as ordered by the physician. This failure had the potential to result in accidents such as choking and aspirating (food, liquid, or other material enters a person's airway and eventually the lungs by accident, causing infections). Findings: During a review of Resident 59's admission Record, the admission Record indicated, Resident 59 was initially admitted to the facility on [DATE] and last admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 59's History and Physical (H&P), dated 3/5/2023, the H&P indicated, Resident 59 did not have the capacity to understand and make decisions. During a review of Resident 59's Minimum Data Set ([MDS]-a standardized assessment and care screening tool), dated 11/28/2023, the MDS indicated Resident 59 was dependent and required assistance (helper does all the effort) from two or more staff for eating, toileting, bathing, dressing, personal hygiene, transfer, and bed mobility. The MDS indicated, Resident 59 was on a Mechanically Altered diet which required change in texture of food or liquids. During a review of Resident 59's Order Summary Report, dated 1/25/2024, the Order Summary Report indicated, a diet order dated 12/6/2022 for a fortified (foods with nutrients added to them) mechanical soft diet with chopped texture and thin liquids. During a review of Resident 59's untitled Care Plan, dated on 8/26/2022, the Care Plan Focus indicated, Resident 59 started on oral diet and gastrointestinal tube ([G-tube]- a tube inserted through the belly that brings nutrition directly to the stomach) feeding was discontinued. The Care Plan Intervention indicated, to provide diet as ordered by the physician, upright positioning, small bites/sips. During a review of Resident 4's admission Record, the admission Record indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and diabetes mellitus (a disorder in which the amount of sugar in the blood is unregulated). During a review of Resident 4's History and Physical (H&P), dated 12/20/2023, the H&P indicated, Resident 59 did not have the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 dependent and required assistance (helper does all the effort) from two or more staff for eating, toileting, bathing, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 12 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dressing, personal hygiene, transfer, and maximal assistance (helper does more than half the effort) from one staff for bed mobility. The MDS indicated, Resident 4 was on a Mechanically Altered diet which required change in texture of food or liquids. During a review of Resident 4's Order Summary Report, dated 1/25/2024, the Order Summary Report indicated, Carbohydrate Controlled (a diet with a consistent amount of sugar through every meal and snack. This prevents blood sugar spikes or falls), fortified, mechanical soft with chopped texture and thin liquids was ordered on 1/5/2024. During a review of Resident 4's untitled Care Plan, dated on 1/5/2024, the Care Plan Focus indicated, Resident 4 had potential nutritional problem and had weight loss. The Care Plan Intervention indicated, use small bites/sips, and upright positioning during oral intake. During an observation on 1/23/2024, at 12:28 p.m., in the kitchen during trayline (assembly of meal trays), Dietary Aid (DA) 2 read Resident 59's meal ticket-fortified, mechanical soft with chopped texture, thin liquid. [NAME] 1 poured melted margarine on chopped seasoned zucchinis and placed whole slice of garlic bread (not chopped) on Resident 59's plate. DA 2 placed the tray in the tray cart (ready for delivery). During an observation on 1/23/2024, at 12:32 p.m., in the kitchen during trayline, DA 2 read Resident 4's meal ticket-controlled carbohydrate, fortified, mechanical soft with chopped texture, thin liquids. [NAME] 1 pour melted margarine on chopped seasoned zucchinis and placed a slice of whole garlic bread (not chopped) on the Resident 4's plate. DA 2 placed the tray in the tray cart and took the tray cart out of the kitchen to deliver trays to the residents. The Food Services Director (FSD) went out of the kitchen and brought back Resident59 and Resident 4's trays back to kitchen. During an interview on 1/23/2024, at 12:42 p.m., with FSD, FSD stated, she was not sure if [NAME] 1 should cut the garlic bread for Residents 59 and 4. FSD stated, she checked the dietary manual, and realized the garlic bread should have been cut into smaller pieces to prevent choking. During an interview on 1/26/2024, at 12:19 p.m. with the Director of Nursing (DON), the DON stated, all residents' meals should be prepared as ordered to prevent possible choking and aspiration. During a review of the facility's Cooks Spreadsheet for Winter Menu (CSWM), undated, the CSWM indicated, Mechanical Soft Garlic Bread-Soft, no hard crusts .Chopped-1/2 (half inch) or less (or specify otherwise). During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2018, the P&P indicated, Procedure:1. The facilities' diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. 2. Menus are written for regular and modified diets in compliance with the diet manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 13 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of infectious agents that could cause food borne illness (food poisoning: any illness resulting from the food spoilage or contaminated food) for 84 out 88 total residents in the facility by not: 1. Ensure Foods were dated, labeled, and discarded before the used by date (expiration dates). 2. Monitoring and maintaining the proper level of the concentration of the quaternary ammonium (a type of chemical that is used to kill bacteria, viruses, and mold) in the sanitization bucket. 3. Monitoring and maintaining minimum safe food serving temperature of 160-degree Fahrenheit ([F]- A temperature scale according to which water freezes at 32 degrees and boils at 212 degrees.) for cooked whole chicken breasts and chopped chicken breasts during trayline (Resident's meal trays are assembled and checked for accuracy before the food is delivered to them). This failure had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: 1. During a concurrent observation and interview on 1/23/2024, at 8:34 a.m., with Food Service Director (FSD), in the dry storage room, there were food items that were not dated and expired as follows: a. An opened loaf of sliced wheat bread with Delivery Date (DD) of 1/22/2024, Open Date (OD)of 1/23/2024, and no Use By ([UB]- the date in which food must be consumed or discarded) date. b. An opened bag of bagels with DD of 1/20/2023, no OD, and no UB. c. An opened bag of thin sliced organic gold seed bread with DD of 1/11/2024, no OD, and no UB. It was supposed to be discarded on 1/18/2024 per the Dry Good Storage Guideline. d. An opened bag of dry pastas in a plastic bin with no DD, OD of 11/7/2023, and UB of 1/7/2024. It was expired. e. An opened bottle of sesame oil with DD of 12/14/2023, no OD, and no UB. f. An opened bottle of light and sweet molasses with no dates. g. An opened bottle of white vinegar with DD of 7/6/2023, no OD and no UB. h. An opened can of baking powder (double strength) in a plastic bin with DD of 6/20/2023, no OD, UB of 11/21/2023. It was expired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 14 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0812 i. An opened can of chicken bouillon powder with DD of 12/19/2023, no OD and no UB. Level of Harm - Minimal harm or potential for actual harm j. An opened container of parboiled rice in a plastic bin with DD of 9/26/2023, OD of 9/26/2023, and UB of 12/26/2023. It was expired. Residents Affected - Some k. An opened bag of dry walnuts with DD of 11/7/2023, no OD, and UB of 11/4/2024 if unopened per guideline. Dry goods storage guidelines indicated it could be stored on shelf for two weeks after opening. l. A can of light tuna with no dates. m. A container of saltine crackers in plastic bin with DD of 8/18/2023, no OD, and UB of 1/18/2024. They were expired. The FSD stated, all food items should have been labeled with received-on-date when the facility got delivery from vendors. The FSD stated, all food items should have an open-on date and a use-by date (expiration date).The FSD stated, it was all dietary staff's (including herself) responsibility to check all food items for labels, dates, and freshness. The FSD stated, all expired items should have been discarded. The FSD stated, these practices were important to make sure all food items were in good condition because the residents consumed these food items. The FSD stated, she would provide an in-service (staff education) for dry food storage guidelines, because once the food items were opened, there is a different shelf life (a time limit on how long a product can be stored before it becomes unsuitable for consumption or use).The FSD stated, all staff should refer to the Dry Goods Storage Guidelines for shelf life after opening and label the UB date on the food items. During a concurrent observation and interview on 1/23/2024, at 8:49 a.m., with the FSD, in the kitchen, there were food items that were not labeled and not dated in Refrigerator #1 as follows: a. An opened jar of jalapeno pickles with DD of 8/30/2023, no OD, and UB b. An opened container of coffee mate liquid with no dates. It should be discarded three weeks after delivery per the Refrigerated Item Storage Guidelines. c. An opened container of whip cream/whipped topping (per the FSD) in plastic container without a label with DD of 1/7/2024, no OD, and no UB. It should be discarded two weeks after thawed from frozen per the Refrigerated Items Storage Guide. d. A plastic container of strawberry Jell-O (per FSD) without label and no date. The FDS stated, all items should be labeled by staff, especially, prepared food items, to ensure safety. The FDS stated, dietary staff should follow the Refrigerated Items Storage Guide to ensure safety of perishable items that require refrigeration. During a concurrent observation and interview on 1/23/2024, at 8:57 a.m., with the FSD, in the kitchen, there were food items that were not labeled, not dated, and expired in the freezer as follows: a. An opened and cut ham wrapped in plastic (per the FSD) without a label with DD of 1/21/2024, no OD, and no UB. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 15 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. An opened box of frozen chicken breasts (per FSD) without a label with DD of 1/21/2024, no OD, and no UB. c. An unopened banana pie with no date. d. An opened container of Tilapia fillets with DD of 1/8/2024, Thaw Date (TD) of 1/9/2024, no OD, and UB of 1/10/2024. It was expired. The FDS stated, dietary staff should follow the Freezer Storage Guideline to ensure safety of perishable (spoil quickly and therefore have a short shelf life) items in the freezer. The FDS stated, all items should be labeled and dated per policy and procedure. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2022, the P&P indicated, all food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation Definitions .The Use By date will be the absolute date in which the food must be consumed or discarded by the facility. Procedure: Food delivered to facility needs to be marked with a delivery or received date .The individual opening or preparing a food shall be responsible for date marking at the time of processing and/or storage .For foods that are prepared by the facility, held greater than 24 hours cold shall be clearly marked to indicate the date by which the food must be consumed or discarded. During a review of the facility's policy and procedure (P&P) titled, Dry Goods Storage Guidelines, dated 2018, the P&P indicated, shelf life for bread was five to seven days after opening and shelf life for nuts were 2 weeks after opening. During a review of the facility's policy and procedure (P&P) titled, Refrigerated Storage Guide', dated 2023, the P&P indicated, opened frozen and thawed whipped topping had shelf life of two weeks after opening and liquid coffee creamer should be discarded three weeks after delivery. 2. During a concurrent observation and interview on 1/23/2024, at 9:22 a.m., with FSD, in the kitchen sink area near the exit door, there was a red bucket of sanitizing solution in the sink without any label. The FSD tested the solution in the bucket with the testing strip and it indicated 0 parts per million ([ppm]- describes the concentration of something in water. One ppm is equivalent to 1 milligram of something per liter of water). The FSD tested the solution again, but still indicated same result. The FSD stated, 0 ppm indicated that there was no quaternary ammonium sanitizer in the bucket. The FSD stated, it should indicate 200 ppm. The FSD stated, it was important to monitor and to maintain quaternary ammonium sanitizer level of 200 ppm (minimum) to kill bacteria, viruses, and mold effectively to ensure food safety for residents. During a review of the facility's policy and procedure (P&P) titled, Quaternary Ammonium Log Policy, dated 2018, the P&P indicated, Policy: The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. Procedure .The food & nutrition worker will place the solution in the appropriate bucket labeled for its contents and will test the concentration of the sanitation solution. The concentration will be tested at least every shift or when the solution is cloudy. The solution will be replaced when the reading is below 200 ppm. 3. During a concurrent observation and interview on 1/23/2024, at 12:10 p.m., with [NAME] 1, in the kitchen during trayline, [NAME] 1 was checking the temperature of cooked lunch items. The temperature on the cooked whole chicken breasts was 162.9F and the temperature of the cooked chopped chicken (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 16 of 17 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 055744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some breasts were 155F. [NAME] 1 stated, she believed it was safe to serve the chicken breasts because the minimum temperature for hot food was 140 F. During an interview on 1/23/2024, at 12:15 p.m., with the FSD, in the kitchen, the FSD stated, minimum safe temperature for poultry was 160 F or above. The FSD stated, anything below 160F was not safe to serve. The FSD stated, [NAME] 1 should ensure the safe temperature of 160F for chicken breasts to prevent food poisoning. The FSD asked [NAME] 1 to remove the chicken from the trayline for safety. During an interview on 1/26/2024, at 12:19 p.m. with the Director of Nursing (DON), the DON stated, all food items should be labeled and dated to serve residents fresh food safely. The DON stated, if the cleaning/sanitizing solution did not meet minimum required concentration to kill bacteria effectively, facility residents might get sick. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2018, the P&P indicated, Policy: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperature .The temperature of the foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperature .Food item Meat, potatoes, rice, pasta-Service temperature of 160F-180F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 17 of 17