Health inspection·January 16, 2025

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 five sampled residents (Resident 4) was not hit by Resident 5. This deficient practice resulted in Resident 4 being punched in the stomach by Resident 5 and had the potential for Resident 4 to suffer physical or psychosocial harm as a result. This deficient practice had the potential for other residents in the facility to be subjected to suffer physical abuse. Findings: 1. 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 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 4 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/10/2024, the MDS indicated Resident 4 ' s cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 4 did not exhibit any behavioral issues and required supervision or touching assistance (helper provides verbal cues and/or touching assistance) for all activities of daily living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) during the assessment period. During an interview on 1/16/2025 at 11:22 a.m. with Resident 4, Resident 4 stated Resident 5 had punched in him the stomach on 1/16/2025 when he was asleep. Resident 4 stated he was scared by being woken up in his sleep and was unsure why he was attacked. 2. During a review of Resident 5 ' s Face Sheet, the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a broad term for any brain disease that alters brain function or structure), schizophrenia, altered mental status, depression (a mental health condition that involves prolonged low mood and loss of interest in activities), and cognitive communication deficit (difficulty in communicating that stems from an impairment in cognitive functions). During a review of Resident 5 ' s MDS, dated [DATE], the MDS indicated Resident 5 ' s cognition was severely impaired. The MDS indicated Resident 5 was dependent (staff does all the effort) for all Page 1 of 2 055995 055995 01/16/2025 North Long Beach Post Acute 260 E Market St Long Beach, CA 90805

F 0600 ADLs. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 5 ' s untitled Care Plan dated 12/20/2024, the Care Plan indicated Resident 5 had a behavior problem related to schizophrenia manifested by agitation and restlessness. Under this Care Plan, the goal included Resident 5 will have no evidence of behavior problems. Residents Affected - Few During a review of Resident 5 ' s Initial Psychiatric Evaluation dated 12/27/2024, the evaluation indicated Resident 5 had a history of schizophrenia manifested by paranoia and agitation towards others, with poor impulse control, judgement, and insight. During an interview on 1/16/2025 at 11:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/16/2025 at approximately 8:30 a.m., she heard a loud commotion and yelling in Resident 4 ' s room. LVN 1 stated upon assessing the situation Resident 4 had told him Resident 5 hit him. LVN 1 stated Resident 5 stated yes when asking if he attacked Resident 4 but did not answer why he attacked Resident 4. During an interview on 1/16/2024 at 3:58 p.m., with the Director of Nursing (DON), the DON stated residents should be free from abuse and the facility should do as much as they can to prevent it from happening. The DON stated Resident 5 ' s behavior could have been more thoroughly analyzed, but she was surprised Resident 5 attacked Resident 4 since her and her staff have not observed him with any aggressive behaviors, and if anything, he was very depressed. During a review of facility ' s policy and procedure (P&P) titled Abuse – Prevention, Screening, & Training Program, revised 7/2018, the P&P indicated the facility does not condone any form of resident abuse with screening and preventions to promote an environment free from abuse. The P&P indicated the facility conducts resident pre-admission screening, admission, and ongoing assessments and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 055995 Page 2 of 2