Inspection·September 13, 2024

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include one of three residents (Resident 1) and/or his Responsible Party (RP 1) in an Interdisciplinary Team ([IDT] a group of professionals with different areas of expertise who work together to achieve a common goal or meet the needs of a resident) Conference when Resident 1 was found sitting on the floor on 7/1/2024. This deficient practice resulted in RP 1 not being aware of Resident 1's change of condition (COC) or their ability to provide input regarding Resident 1's care. This deficient practice had the potential for Resident 1's care needs to go unmet. Findings During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizoaffective disorder (a mental illness which affects a person's mood and behavior). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/12/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half the effort) for completion of his activities of daily living ([ADL] task such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating). During a review of Resident 1's COC Assessment Form dated 7/1/2024, the COC indicated Resident 1 was found sitting on the floor. During a review of Resident 1's Interdisciplinary Narrative, dated 7/18/2024, the IDT Narrative indicated Resident 1 exhibited a behavior of sitting on the floor due to his culture and it was the Resident 1's preference to sit on the floor. The IDT narrative indicated Resident 1, and/or RP 1 did not attend the IDT conference. During an interview on 9/12/2024 at 12:03 p.m., RP 2 stated it was not part of Resident 1's culture to sit or pray on the floor. During an interview on 9/13/2024 at 9 a.m., RP 1 state she was not informed about an IDT meeting or that Resident 1 was found sitting on the floor. RP 1 stated Resident 1 does not like to sit on the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 056043 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 056043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Care Center 1913 E 5th Street Long Beach, CA 90802 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)