Health inspection·December 3, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 12/3/2024, at 10:30 a.m. with Resident 1, Resident was lying in bed in an upright position and stated she had not gone out of bed in a wheelchair for almost a week. Resident 1 stated her motorized wheelchair was broken and she used the motorized wheelchair to get around the facility. Resident 1 stated she was not refusing to get out of bed in a manual wheelchair and the facility was not offering it to her. Residents Affected - Few During an interview on 12/2/2024, at 12:42 p.m. with Certified Nursing Assistant (CNA1), CNA1 stated Resident 1 never gets out of bed to the wheelchair since the motorized wheelchair was broken. CNA1 stated the resident would feel angry if she was not able to use a wheelchair to go to the patio or the kitchen to ask for a soda. During an interview on12/2/2024, at 1:20 p.m. with Maintenance Supervisor (MS). MS stated he was notified by Resident 1 two weeks ago that her motorized wheelchair broke down. MS stated the facility did not have motorized wheelchair on site nor able to rent a motorized wheelchair and the issue was referred to the medical equipment company who would be coming this week to repair the wheelchair. During a concurrent interview and record review of Resident 1 ' s chart in electronic and hard copy on 12/2/2024, at 3:19 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated she only saw Resident 1 was up in a manual wheelchair ever since the motorized wheelchair broke down. LVN 2 confirmed there was no documentation in the chart about resident ' s refusal to use the manual wheelchair or refusal to get out of bed to the wheelchair. During a concurrent interview and record review of Activities of Daily living (ADL- activities such as bathing, dressing, and toileting a person performs daily) tasks on 12/2/2024, at 3:45 p.m. with RN Supervisor (RNS1), RNS 1 stated Resident 1 would usually in her motorized wheelchair every day. RNS 1 confirmed Resident 1 did not get out of bed or used the wheelchair for eight days. RNS 1 stated there are other options if the resident ' s motorized wheelchair was not available, the staff could use a Geri chair( a large , padded chair that is designed to help people with limited mobility) or manual wheelchair to get Resident 1 out of bed to the chair. RNS 1 stated Resident 1 could be at risk for depression or development of skin breakdown due to immobility. During a review of ADL Task for Wheelchair/ Scooter Use, the ADL task indicated the resident did not use the wheelchair on 11/19/2024, 11/20/2024, 11/21/2024, 11/23/2024, 11/25/2024, 11/26/2024. 11/28/2024, 12/1/2024 and 12/2/2024. During a concurrent interview and record review of Resident 1 ' s charts, on 12/2/2024, at 4:30 p.m. with Director of Nursing (DON), DON confirmed there was no documentation in the chart refused the manual wheelchair and if a resident refusing care like getting out of bed in a wheelchair documentation about refusal and Care planning should be in the resident ' s charts. DON stated the staff should have offered the manual wheelchair, Geri chair or recliner and not wait for the motorized wheelchair to get repaired. DON stated Resident 1 could be at risk foe feeling frustrated and sad for not able to get around the facility like she used to do. During a review of facility ' s policy and procedure (P&P) titled Resident Rights dated 9/2017, the P&P indicated the resident has the right to reside and receive services with reasonable accommodation of needs and preferences unless it will endanger the health and safety of the resident or ither residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056007 If continuation sheet Page 2 of 4 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 056007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Care Nursing Center 3355 Pacific Place 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to observe infection control measures by failing to perform a Covid test ( screening test to rule out Covid-19 illness) on one of four sampled residents (Resident 2) who was showing signs and symptoms of a respiratory illness in a timely manner. Residents Affected - Some This failure had the potential to put other residents and staff at risk for infection. Findings: During a review of Resident 2 's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included asthma( condition where a person's airways become inflamed, narrow, and swollen and produce extra mucus making harder to breathe), unspecified dementia( progressive state of decline in mental abilities), and history of Covid -19(viral and contagious respiratory illness). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool)dated 10/19/2024, the MDS indicated the resident had severe cognitive skills( problems with a person's ability to think, learn, remember, and make decisions) and required substantial/ maximal assistance ( helper does more than half of the effort) with bed mobility ,personal hygiene, and oral hygiene. During a review of Resident 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 11/17/2024, the SBAR indicated the resident had a change in condition and signs observed were abnormal chest x-ray , elevated white blood count of 18,000 (WBC - a blood test that measures the number of white blood cells and an elevated WBC count can indicate the body is fighting an infection) and pneumonia (an infection /inflammation in the lungs). During a review of Resident 2's covid Test , the covid test indicated the resident was tested for covid on 11/18/2024. During an interview on 12/2/2024, at 10:30 a.m. with Resident 1, Resident 1 stated Resident 2 who was her roommate had been coughing a lot and she was afraid of getting sick because of Resident 2's cough. During an interview on 12/2/2024, at 4:04 p.m. with Licensed Vocational Nurse (LVN1), LVN 1 stated she noticed Resident 2 was having episodes of productive cough(cough that produces mucus or phlegm) while sitting in the hallway on 11/16/2024. LVN 1 stated she notified RN Supervisor (RN1) and the resident was started on antibiotics(medicine used to treat infection). During an interview on 12/2/2024, at 3:45 p.m. with RN Supervisor (RNS 1), RNS 1 stated LVN 1 and unnamed Certified Nursing Assistant notified her about Resident 2's cough on 11/16/2024. RNS 1 stated Resident 2 had productive cough and was wheezing ( shrill, coarse whistling sound your breath makes when the airway is partially blocked or narrowed) during assessment. During a concurrent interview and record review of Resident 2's chart on 12/2/2024, at 5:16 p.m. with Infection Preventionist Nurse (IPN), IPN stated the facility screens residents manifesting symptoms of congestion, cough and fever for covid or flu. IPN stated the facility should have tested (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056007 If continuation sheet Page 3 of 4 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 056007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Care Nursing Center 3355 Pacific Place 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 2 for covid when symptoms appeared on 11/16/2024 and not wait two days later. IPN stated it's important to screen residents who are showing symptoms like cough and congestion to prevent an outbreak or spread of infection in the facility. During an interview on 12/2/2024, at 5:38 p.m. with Director of Staff Development (DSD), DSD stated the facility test residents for covid if manifesting any symptoms of congestion, cough, fever or lethargy ( sleepiness) . DSD stated the staff should have tested Resident 2 for covid based on her symptoms of productive cough and wheezing. DSD stated the reason the covid test was not done because the staff waited for the DSD to do the test. DSD stated all licensed nurses could do the covid test and were trained how to perform the covid test. During a telephone interview on 12/3/2024, at 9:57 a.m. with Director of Nursing (DON), DON stated the staff should not have to wait for the IPN to do the test for Covid. DON stated the staff should call the physician for any symptoms of respiratory disease and get an order for Covid test. DON stated not screening and testing residents for covid or flu who are showing symptoms of respiratory illness could put other residents at risk for exposure to infection. During a review of facility's policy and procedure (P&P) titled Infection Control Program System dated 1/2023, the P/P indicated the facility had an established infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The P&P indicated the facility maintains written standards, policies and procedures which included a system of surveillance designed to identify possible communicable diseases or infection before they can spread to other residents in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056007 If continuation sheet Page 4 of 4