Health inspection·November 13, 2024

F 0657 Resident 1 had the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/9/2024, the MDS indicated Resident 1 had moderate cognitive impairment and always had the ability to be understood and to understand others. The MDS indicated had functional limitation in range of motion on the left lower extremity. Resident 1 required partial/moderate assistance (helper does less than half the effort) for toilet hygiene, showering/bathing and personal hygiene. The MDS indicated Resident 1 had a major surgical procedure that requires active care during the skilled nursing facility stay. Residents Affected - Few During a review of Resident 1's Order Summary Report (Physician's Orders), dated 9/26/2024 the Order Summary Report indicated left AFO for foot drop/compartment syndrome. During a review of Resident 1's Order Summary Report (Physician's Orders), dated 11/8/2024 the Order Summary Report indicated Vendor A to evaluate and provide custom molded left AFO to correct ankle/foot deformity and improve dorsiflexion to provide support during ambulation. During a review of Resident 1's Clinical Record (Care Plan section), initiated on 9/5/2024, the Care Plan indicated Resident 1 has actual impairment to skin related to surgical wound, status post fasciotomy (surgical procedure that involved cutting open the fascia[connective tissue that surrounds muscles, nerves and blood vessels] to relieve pressure), the Care Plan goal indicated Resident 1 will have no complications related to skin injury through a review date of 12/23/2024. The Care Plan's interventions indicated for Resident 1 to have a follow-up appointment with physician 1, a follow up appointment with the vascular surgeon, and to follow up with General Acute Care (GACH) wound healing and limb preservation center. During a review of Resident 1's Clinical Record (Care Plan section), initiated on 9/19/2024, the Care Plan indicated Resident 1 had alteration in musculoskeletal system related to risk of foot drop, the Care Plan goal indicated Resident 1 will remain free of complications related to fracture, such as contracture formation (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), embolism (obstruction or blockage in a blood vessel) and immobility through review date of 12/23/2024. The Care Plan interventions included PRAFO boots to left foot, educate family/resident/caregivers on joint conservation techniques, referral to orthotist for better treatment of foot drop. During a review of Resident 1's Interdisciplinary Team Meeting Note (IDT), dated 9/18/2024, the IDT notes indicated therapy services plan of care as follows: reviewed progress of therapy with daughter, discussed concerns for left foot drop status post fasciotomy, and daughter will follow up with physician on 9/19/2024. The IDT note indicated the following: resident and/or resident representation (RP) have been notified of their right to participate in the development and implementation of her person centered plan of care, including the right to see care plan and sign off after significant changes are made; the resident and or RP have been notified of their right to receive a written summary of the residents plan of care, including the baseline care plan. During a review of Resident 1's Physical Therapy Notes, dated 10/18/2024, the Physical Therapy Notes indicated physician 1 requested the following: therapy to work on aggressive range of motion to left ankle to improve dorsiflexion ([DF] upward movement of the foot and ankle), requesting a new left AFO for walking with more dorsiflexion, add padding under toes of current AFO to promote more DF. The note indicated physician 1 is okay with black Pressure Relief Ankle Foot Orthosis (PRAFO- a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 2 of 6 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 11/13/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few device that helps prevent and manage pressure-related problems in the feet and ankles, used for residents whom spend long periods in bed or a wheelchair, not designed for prolonged walking or standing) when at rest but it would be okay with a new one to provide more DF stretch, requests relayed to social services to obtain authorization for another orthotic appointment and rehab team made aware. During a review of Resident 1's Physical Therapy Notes, dated 10/22/2024, the Physical Therapy note indicated the following precautions: left lower extremity weight bearing as tolerated as of 9/26/2024, black PRAFO only at rest (no gait training), must gait train with [NAME] Solid AFO with DF assist (padding under big toe). During a review of Resident 1's IDT note dated 10/23/2024, the note indicated the following : DON spoke with RP 1 to discuss the plan of care for Resident 1, RP 1 stated physician 1 visited Resident 1 in facility an recommended a different boot and more days for rehabilitation treatment for foot drop, DON explained to RP 1 that Resident 1 I on part B, to receive therapy three times a week at the moment. The Social Services Director (SSD) has submitted different authorizations for different orthosis vendors DON informed RP 1 that due to Resident 1's being custodial status, the process is different and may take longer. The Director of Rehabilitation (DOR) spoke with Resident 1's nurse practitioner (NP) 1 regarding Resident 1's therapy treatment and was informed that NP 1 may increase Resident 1's physical therapy day after new boot has arrived. During an interview on 11/4/2024, at 12:34 p.m., the RP1 stated her primary concern in Resident 1's care is the prevention and management of Resident 1's foot drop. RP 1 stated she was in communication with multiple individuals including the DON, the DOR, physical therapist (PT)1 related to the management and prevention of Resident 1's foot drop. RP 1 stated, upon Resident 1's admission an IDT meeting was held sometime in September and a plan of care was discussed. RP 1 stated the plan of care was not finished and it was dependent on the result of Resident 1's post-surgical follow up appointments. RP 1 stated after the IDT, Resident 1 had several physician appointments with the vascular surgeon and wound care physician in which the physicians recommended continued physical therapy to prevent foot drop. RP 1 stated Resident 1 experienced several changes in payer sources directly affecting the frequency of physical therapy services in addition to requiring multiple adjustments to made to Resident 1's AFO and PFO orthosis. RP 1 stated she felt confused and frustrated not receiving a clear revised plan of care reflecting all the changes in Resident 1's plan of care. RP 1 stated, I feel like I was having so many conversations with different people in the healthcare team such as the DON, DOR and PT that was very stressful, confusing, and frustrating. RP 1 stated it seems the IDT was unaware of the modifications that were needed for Resident 1's AFO to properly prevent and manage foot drop. RP 1 stated, I had authorizations sent to me by insurance that I did not know had to be given to the facility to schedule another orthosis fitting because no one told me. During a concurrent observation and interview on 11/8/2024 at approximately 12:30 p.m., with Vendor 1 in Resident 1's room, Resident 1 was observed lying in bed. Vendor 1 stated he just finished fitting Resident 1 for the appropriate orthotic boot. Vendor 1 stated when Resident 1 was initially fitted and molded for the boot, Resident 1's left foot was not positioned in the correct way causing the boot not to fit properly and did not provide the appropriate support the foot to prevent foot drop. Vendor 1 stated the boot will be ready and arrive to the facility in about two weeks. During an interview on 11/8/2024, at 1 p.m., Resident 1 stated she must wear a boot on her left foot to prevent foot drop. Resident 1 stated her boot is not fitting properly and was just finished being fitted for the correct one. Resident 1 stated her daughter is the RP 1 and makes the decisions in her care. Resident 1 stated she has had problems with her boots fitting and had to wait on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 3 of 6 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 11/13/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few authorizations from insurance company to authorize modifications to the boot. Resident 1 is not sure what her plan of care because of the many doctors she sees and her boots not fitting. During an interview on 11/8/2024 at 1:58 p.m., with the Physical Therapist (PT), PT 1 stated Resident 1 is at risk for worsening foot drop. PT 1 stated when Resident 1 was admitted to the facility, Resident 1 did not have any ankle support devices to prevent foot drop. PT 1 stated once Resident 1 was cleared by her vascular surgeon for physical therapy on her left foot, Resident 1 was fitted for an orthotic boot which arrived on approximately 10/11/2024. PT 1 stated when the boot arrived, it did not properly fit Resident 1 and was restrictive to Resident 1's movements. PT 1 stated, Resident 1 has required an additional fitting which was delayed to miscommunication with RP 1 and insurance changes. PT 1 stated Resident 1's current orthotic device which she is using do not provide her with proper support aimed to prevent worsening foot drop. PT 1 stated on 10/18/2024 Resident 1 was assessed by physician 1 who stated padding should be added under the toes to promote Dorsiflexion. PT 1 stated Resident 1's physician orders nor care plan have not been revised reflect the additional padding placed to support Resident 1's toes. The care plan does not address the improper fit of Resident 1's current orthotic brace and that the Resident 1 is awaiting a new brace to arrive. PT 1 stated the IDT has not met to discuss changes. The care plans and physician orders do not indicate the specific use of the AFO boot vs the PRAFO boot. During an interview on 11/13/2024 at 12:39 p.m., with Certified Nurse Assistant (CNA), CNA 1 stated she is Resident 1's assigned CNA for the day shift. CNA 1 stated, I see that Resident 1 had a boot and a splint on her left leg, but I do not know what it is for. During an interview on 11/13/2024 at 12:45 p.m., with the Restorative Nursing Assistants (RNA) 1 and 2, RNA 1 and 2 stated they are the RNAs assigned to Resident 1's care. RNA 1 and 2 stated, Resident 1 wears a brace on her left foot to prevent injury. RNA 1 and 2 did not know the reason for the device was to prevent foot drop for worsening. RNA 1 and RNA 2 stated the information was not provided to them by the IDT and it would be beneficial to know why Resident 1 was using a brace to ensure we are provided her the proper care, and it will give us information to notify the nurse if there is something wrong. During an interview on 11/13/2024 at 1:10 p.m., with Licensed Vocational Nurse (LVN), LVN 1 stated she is Resident 1's assigned licensed nurse for the day shift. LVN 1 stated, Resident 1 wears a brace and a special shoe to prevent foot drop on her left leg, but physical therapy department handles it usage and application. LVN 1 stated she did not receive specific training on the different types of orthotic devices and boots Resident 1 uses. LVN 1 stated the licensed nurses should be included on Resident 1's plan of care to ensure the proper usage and application of the boot incase the licensed nurses must remove the boot during the night shift or hours the physical therapy department available in the facility. LVN 1 stated, Resident 1 is recovering from a wound on her left lower leg so nursing assesses any changes in the skin of her lower leg that may demonstrate infection of decreased circulation. LVN 1 stated there may be a possibility for nursing to remove the orthosis during the time PT is not available. During an interview on 11/13/2024 at 2 p.m., with the Director of Rehabilitation (DOR), the DOR stated Resident 1 was delayed in being refitted for the AFO orthosis due to miscommunication between the facility and RP 1. The DOR stated the facility was waiting on authorization from Resident 1's insurance to refit the orthosis. The DOR stated RP 1 received the needed authorizations from the orthotic vendor but did not know to give the facility a copy which caused the delay in Resident 1 receiving the proper support for to treat her foot drop. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 4 of 6 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 11/13/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm During a subsequent interview on 11/13/2024 at 2:10pm, with the DOR, the DOR stated upon his review of Resident 1's physical therapy notes, the listed precautions indicating the specific usage of PRAFO boots vs AFO were not reflected in Resident 1's care plan or physician orders. DOR stated it is important for the Resident 1's care plan to reflect the proper usage of orthotic boots. DOR stated he will be calling Resident 1's physician 1 to clarify orders. Residents Affected - Few During an interview on 11/13/2024 at 2:58 p.m., with the Minimum Data Set (MDS) Nurse, the MDS Nurse stated she is part of the IDT team and helps to coordinate IDT team meetings with residents and/or their RP. The MDS nurse states she assists developing care plans that are resident centered and specific to goals and reflects changes in the residents' plan of care. The MDS nurse stated the IDT consists of nurse, social services, dietary services, activities department, RNAs and CNAs. The MDS nurse stated it is important for the IDT to work together with the resident and or the RP to develop the residents' plan of care. The MDS nurse stated it is important for all members of the healthcare team, including those providing direct daily care to the resident (licensed nurses and CNAs) to be informed of the resident's care plan goals and interventions to ensure the proper care and services are provided. The MDS nurse stated the healthcare team should revise the care as needed to reflect any changes or new problems affecting the resident and their plan of care. During a subsequent interview on 11/13/2024 at 3:10 p.m., with the MDS nurse, the MDS nurse stated the care plans did not reflect the specific indications of when to use the PRAFO vs AFO boot. The care plans did not reflect that RP 1 was provided updates or informed of the necessary modifications to be made on Resident 1's orthotics. During an interview on 11/13/2024 at 4 p.m., with the DON, the DON stated upon her review of Resident 1's physical therapy notes she was not aware of the modifications made to Resident 1's orthosis to ensure the prevention of foot drop. The DON stated the last IDT meeting was held on 10/23/2024 to include the RP 1. The DON stated RP1 speaks with many members of the IDT independently which can cause confusion and misunderstandings in Resident 1's plan of care. The DON stated Resident 1's care plan should have been updated to reflect the pending arrival of Resident 1's properly fitted orthosis. The DON stated the care plans should also reflect the specific instructions indicating the proper usage of the current boot, which includes the work around of adding the padding under Resident 1's toes to provide support. The DON stated, the care plan should indicate when direct care staff should use the AFO and the PRAFO boot. The DON stated the IDT team including CNAs, and licensed nurses should be aware of Resident 1's plan to care to perform the appropriate assessments and to deliver the needed services. The DON an updated and revised care plan will help to ensure the IDT members and RP 1/Resident 1 have a clear understanding of Resident 1's plan of care. The DON stated failing to update and revise Resident 1's care plan can lead to miscommunication within the IDT team lead and between the IDT and RP 1 which can result in a delay in care and services and distrust and frustration from RP 1. During a review of the facility's policy and procedure (P&P) titled, Care Planning, revised May 2007, the P&P indicated the IDT team shall develop a comprehensive care plan for each resident. The IDT includes but is not limited to the following professionals: attending physicians, or non-physician practitioner (NPP), registered nurse responsible for resident, nurse aide responsible for resident, member of food and nutrition services staff, to extent practicable, resident and or RP, other appropriate staff or professional in disciplines as determined by resident's needs or requested by resident. During a review of the facility's P&P titled, Resident Rights, dated 10/4/2016, the P&P indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055744 If continuation sheet Page 5 of 6 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 11/13/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the Resident Rights include the right to be informed of and participate in your treatment including the right to be fully informed of your total health status, including but not limited to your medical condition, the right to participate in the development and implementation of your person centered plan of care, the right to receive information in a form and manner you can understand. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, revised 8/2017, the P&P indicated the IDT will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Event ID: Facility ID: 055744 If continuation sheet Page 6 of 6