Health inspection·November 6, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few Residents make none of the effort to complete the activity) with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. The MDS indicated no indicators of pain or possible pain in the last five days of assessment (8/19/2025). During a review of Resident 1's Physician's Order dated 10/21/2025 at 3:30 p.m., the Physician's Order indicated to have a Stat (immediately) X-ray of Resident 1's right hip and right femur. During an observation on 11/5/2025 at 10:55a.m., Resident 1 was observed lying down on a low bed. Resident 1 was observed with both legs contracted (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) drawn toward the chest. The right hip area was observed with multiple stitches (piece of special thread used to hold the edges of a wound together to promote healing) due to [NAME] surgery done on 10/24/2025. During a concurrent observation and interview on 11/5/2025 at 11:00 a.m., with Licensed Vocational Nurse (LVN 1) in Resident 1's room, LVN 1 stated Certified Nursing Assistant (CNA) 1 observed Resident 1 on 10/21/2025 at approximately 1:45 p.m. making facial grimaces, (strong emotions suggestive of pain), and noted Resident 1's right hip appeared unstable wobbling, indicating an abnormal range of motion (ROM- the full movement potential of a joint or series of joints in a specific direction) compared to the resident's usual contracted position. LVN 1 stated CNA 1 immediately reported to her (LVN 1) and she informed Registered Nurse (RN) 1. LVN 1 stated RN 1 assessed Resident 1 but opted not to perform a more extensive physical assessment to avoid more complication. LVN 1 stated RN 1 noted the resident's right hip area was hot to touch. During a telephone interview on 11/5/25 at 11:34 a.m., with CNA 1, CNA 1 stated she was not certain of what happened to Resident 1's right hip. CNA 1 stated the splint (a supporting device made of hard material to protect a body part) applied on both lower extremities around the knees may have been too tight or pulled. CNA 1 stated that she began caring for Resident 1 on 10/21/2025 at the start of her shift (7:00 a.m. to 3:00 p.m.). CNA 1 stated she did not observe abnormalities during routine morning care on 10/21/2025 at approximately 10 a.m. CNA 1 stated on 10/21/2025 around 1:45 p.m., when she checked Resident 1, she observed the resident making facial grimaces. CNA 1 stated she noted Resident 1's right leg appeared loose and the right hip unstable. CNA 1 stated she immediately notified the charge nurse (LVN 1). CNA 1 stated Resident 1 wears a splint, with her legs typically positioned together, ankles overlapping, and drawn toward the chest. CNA 1 stated the Restorative Nursing Assistant (RNAnursing aide program that helps residents to maintain their function and joint mobility) worked with the resident on 10/21/2025 at approximately 10:45 a.m. During the interview on 11/5/25 at 11:40 a.m., with RNA 1, RNA 1 stated she provides residents with ROM and splinting. RNA 1 stated Resident 1 had an order for knee splints for both lower extremities. RNA 1 stated she spread apart both Resident 1's knees and apply splints on 10/21/2025. RNA 1 stated Resident 1 was very contracted on both lower extremities and fragile. RNA 1 stated on 10/21/2025, she performed ROM to Resident 1 after Resident 1 was pre medicated with Tylenol (pain medication) and cleaned by CNA 1. RNA 1 stated when she performed ROM and applied knee splints to Resident 1 at 10:45 a.m., the resident was fine and tolerated the treatment. RNA 1 stated at approximately 2:45 p.m., RN 1 asked her why Resident 1's legs were loose. RNA 1 stated she does not know what happened to Resident 1's leg as it was okay when she did ROM and applied knee splints on 10/21/2025 at 10:45 a.m. During an interview on 11/5/25 at 1:05 p.m., with RN 1, RN 1 stated LVN 1 reported to her regarding Resident 1's wobbly leg. RN 1 stated when she assessed Resident 1's leg, she did not observe any swelling, but the right hip area was hot to touch. RN 1 stated she called Resident 1's medical doctor (MD) 1 and received an order on 10/21/2025 at 3:30 p.m., for stat x-ray to right hip and right femur. RN 1 stated LVN 1 gave Resident 1 Tylenol (pain medication) 500 milligrams (mg-unit of measurement) two tablets for pain scale (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056043 If continuation sheet Page 2 of 5 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 11/06/2025 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few pain scale rating of 7/10 ( zero to ten pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). During an interview on 11/5/2025, at 2:55 p.m., with LVN 1, LVN 1 stated pain assessment was based on Resident 1's facial expression, which was the reason the resident was medicated with Tylenol (pain medication). LVN 1 stated Resident 1 received Tylenol 500 mg (2 tablets) on 10/21/2025, at 2:14 p.m. and at 4:17 p.m. LVN 1 stated during the night shift ( 11 p.m. to 6 a.m.) Resident 1 received Norco ( narcotic pain medication used to manage moderate to severe pain) 5/325 mg one tablet on 10/22/2025 at 5:12 a.m., and 9:11 a.m. LVN 1 stated Resident 1 was transferred to GACH on 10/22/2025 approximately 11 a.m. LVN 1 stated Resident 1 hip and femur x-ray result was received on 10/22/2025 at 1:22 a.m. LVN 1 stated Resident 1's x-ray result was faxed to MD 1 at that time (1:22 a.m.). LVN 1 stated MD 1 was notified of Resident 1's x-ray result on 10/22/2025 at 8:35 a.m., and an order was received to transfer Resident 1 to the GACH. During an interview on 11/5/2025 at 3:10 p.m., with LVN 2, LVN 2 stated he received orders from Resident 1's physicians on 10/22/2025 approximately 9 a.m., to transfer Resident 1 to GACH. LVN 2 stated RN 3 called the ambulance, and the ambulance arrived around 11 a.m. During a telephone interview on 11/6/25 at 10:50 a.m., with RN 2, RN 2 stated she received the faxed x-ray results indicating Resident 1 had femoral fracture on 10/22/2025 at 1:22 a.m. RN 2 stated she immediately faxed the results to Resident 1's MD and informed the Assistant Director of Nursing (ADON). RN 2 stated she called Resident 1's MD on 10/22/2025 at 6:00 a.m. and spoke with the receptionist. RN 2 stated she did not receive an order to transfer Resident 1 to GACH until the end of her shift (11 p.m. to 7 a.m. shift). RN 2 stated during her initial rounds on 10/21/2025 at approximately 11:30 p.m., she observed the resident sleeping. RN 2 stated at around 12:30 a.m., Resident 1 opened her eyes and was noted to have swelling of the right hip. RN 2 stated she did not contact the medical director when she received the x-ray result because she received an order from MD 2 to wait until a.m. RN 2 stated she assumed a.m. means 6 a.m. since there was no specific instruction to call at a particular time in the morning and her understandings that morning referred to 6:00 a.m. RN 2 stated she typically expects a physician to call-back within 15 to 20 minutes, but with Resident 1' s positive x-ray result for fracture she was unable to follow up with the MD.During a review of Resident 1's Medication Administration Record (MAR) dated 10/21/25 at 2 p.m., the MAR indicated Tylenol Extra strength 500 mg two tablets were given to Resident 1 for pain level of 7/10, and Tylenol 500 mg two tablets were given to Resident 1 on 10/21/25 at 4:17 p.m. for pain level of 5/10 rated by facial grimacing. During a review of Resident 1's Nursing Progress Note dated 10/21/2025 at 2:20 p.m., the Nursing Progress Notes indicated at 2 p.m., LVN 1 informed RN 1 regarding Resident 1's right leg ( appeared wobbly and loose with swelling). The Nursing Progress Notes indicated Resident 1 was observed with facial grimacing indicating the resident had 4/10 pain on a facial expressions pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). The Nursing Progress Notes indicated Resident 1 administered Tylenol 500 mg two tablets via gastrostomy tube (GT- a medical device [used to prevent or treat a disease] used for feeding, hydration, and medication). During a review of Resident 1's Nursing Progress Note dated 10/21/2025 at 3:17 p.m., the Nursing Progress Notes indicated CNA 1 reported Resident 1 was observed with increased facial grimacing during resident care while repositioning. The Nursing Progress Notes indicated Resident 1 had an increase in pain each time Resident 1 was repositioned. During a review of Resident 1's Physician Order dated 10/21/2025 at 8:56 p.m., the Physician Order indicated an order for Norco oral tablet 5-325mg one tablet to be given through G-Tube every four hours as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056043 If continuation sheet Page 3 of 5 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 11/06/2025 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few needed for severe pain ranging (6 to 9 out of ten) on a pain rating scale. During a review of Resident 1's Nursing Progress Note dated 10/21/2025 at 9:21p.m., the Nursing Progress Notes indicated that on 3 p.m., to 11 p.m., shift Resident 1 was observed restless with facial grimacing. Resident 1was in severe pain with swelling on right thigh, warm and tender to touch with redness, abnormal rotation of right thigh extending to the femur/knee. The Nursing Progress Note indicated Resident 1 was given Tylenol extra strength two tablets for moderate to severe pain. The Progress Notes indicated RN 1 received an order from Resident 1's physician on 10/21/2025 at 3:30p.m., to do x-ray of the right hip and right femur. The Progress Notes indicated RN 2, paged Resident 1's MD for an order for strong pain medication. The Progress Notes indicated on 10/21/2025 at 8:56 p.m., received MD order for Norco (pain medication used to manage moderate to severe pain) 5/325 mg every four hours as necessary (PRN) for seven days. The Progress Notes indicated Resident 1 received Norco 5/325 mg on 10/21/2025 at 10 p.m. The Progress Notes indicated MD 2 ordered to call MD 1 in a.m., if x-ray result was positive for fracture to get order to transfer Resident 1 out to the hospital. During a review of Resident 1's Nursing Progress Note dated 10/22/2025 at 12:10 a.m., the Nursing Progress Notes indicated Resident 1 was observed with minimal to moderate swelling to the right leg and right knee, and it was very warm to touch. The Nursing Progress Notes indicated Resident 1 had increased facial grimacing with beads of sweat (small, round droplets of perspiration on the skin, which can be caused by physical exertion, heat, or stress). The Nursing Progress Notes indicated Resident 1's right leg swelling has doubled in size. During a review of Resident 1's Radiology (a medical document that describes the results of an imaging test, such as an x-ray) Report dated 10/21/2025, the Radiology Report indicated right femoral fracture with soft tissue swelling. The Radiology Report was electronically signed by the radiologist (a medical doctor who specializes in diagnosing and treating diseases and injuries using medical imaging techniques like x-rays) on 10/22/2025 at 12:31 a.m. During a review of Resident 1' s MAR dated 10/22/25 at 5:12 a.m. Norco one tablet 5-325mg was given to Resident 1 for severe pain of 6/10 rated by facial grimacing and moaning/groaning. Norco one tablet 5-325mg was administered to Resident 1 on 10/22/25 at 9:17 a.m. for severe pain level of 9/10 rated by facial grimacing and crying. During a review of Resident 1's Nursing Progress Note dated 10/22/2025 at 5:29 a.m., the Nursing Progress Notes indicated Resident 1 had a swelling on the right thigh with facial grimacing when touch. During a review of Resident 1' s Nursing Progress Note dated 10/22/2025 at 8:15a.m., the Nursing Progress Note indicated Resident 1 was monitored for status post-acute right proximal femoral fracture. The Nursing Progress Note indicated Resident 1 was observed awake and alert resting in bed with episodes of facial grimacing. The Nursing Progress Notes indicated a pain assessment of 7/10 based on non-verbal scale. The Nursing Progress Note indicated Resident 1 had short period of hyperventilation (breathing too fast or too deeply), ventilator alarming, occasional moaning/groaning, facial grimacing, rigidity and clenched fists. The Nursing Progress Note indicated Resident 1's right leg appeared with moderate swelling, slight yellow tinged discoloration, and flaccidity ( part of the body that is hanging loosely) with increased ROM. During a review of Resident 1's Care Plan titled Resident 1 has the potential for alteration in comfort due to pain related to proximal femoral fracture, soft tissue swelling dated 10/22/25, the Care Plan intervention indicated to monitor signs and symptoms of pain, flinching, moaning, crying, grimaced facial expression and inform physician promptly, provide nursing comfort measures, assess characteristics of pain, location, duration, quality, aggravating and alleviating factors, radiation (pain that begins in one area and spread to another), intensity and document, administer medication as ordered, monitor effect of medication, provide pain medication prior to planned expected activities. During a review of Resident 1's Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056043 If continuation sheet Page 4 of 5 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 11/06/2025 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Progress Notes dated 10/22/2025, at 9:05 a.m., the Nursing Progress Notes indicated Resident 1 was resting in bed with facial grimacing. Resident 1's non-verbal pain scale score was documented as 9/10. Resident 1 exhibited a short period of hyperventilation, ventilator alarms, crying, facial grimacing, rigidity, clenched fists, and was unable to be consoled by voice or touch. Resident 1 was given Norco 5/325 mg on 10/22/2025 at 9:11 a.m. The Nursing Progress Notes indicated, during a room check at 10:00 a.m., Resident 1 continued to display signs of distress, including hyperventilation, facial grimacing, rigidity, and clenched fists. The Nursing Progress Notes indicated at 10:30 a.m., a pain reassessment was conducted, with a non-verbal pain scale score of 5/10. Resident 1 continued to exhibit occasional moaning/groaning, facial grimacing, and a tense effect. The Nursing Progress Notes indicated at 12:19 p.m. Resident 1 was transported out of the facility. During a review of Resident 1's Pain Assessment, the Pain Assessment indicated the following:1. On 10/21/25 at 2 p.m. Resident 1 pain level was 7/10 and reassessed at 2:30p.m. with pain level of 3/10 rated by facial grimacing.2. On 10/21/25 at 4:13 p.m. and 4:17p.m., Resident 1 pain level was 5/10 rated by facial grimacing. 3. On 10/21/25 at 11:10 p.m. and 11:15 p.m., Resident 1 pain level was 6/10 rated by facial grimacing. 4. On 10/22/25 at 5:12 a.m., Resident 1 pain level was 6/10 rated by facial grimacing and crying.5. On 10/22/25 at 8:15 a.m., Resident 1 pain level was 7/10 rated by facial grimacing and crying, rigid, fist clenched. 6. On 10/22/25 at 9:11 a.m., Resident 1 pain level was 9/10 rated by facial grimacing, crying, rigid, fist clenched. 7. On 10/22/25 at 10:30 a.m., Resident 1 pain level was 5/10 rated by facial grimacing, groaning/moaning. During a review of Resident 1' s GACH Record titled Consultation Report dated 10/24/2025 , the Consultation Report indicated Resident 1 was admitted to the hospital on [DATE] for pain in the right hip, probably due to a pathological fracture from severe osteoporosis. The GACH Record indicated Resident 1 had a surgical procedure [NAME] procedure with left hip disarticulation (removing the entire left leg by detaching it at the hip joint) done on 10/24/2025 at 12:31 p.m. During a review of Resident 1's Emergency Department (ED) Report dated 10/22/2025, the ED Report indicated Resident 1 arrived at the ED from nursing home because staff noticed swelling and redness to Resident 1's right thigh and x-ray found possible femur fracture. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or status dated 2/2021, indicated the facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition.The nurse will notify residents attending physicians on call when there has been a/ an:An accident or incident involving the residenta. Discovery of injuries of an unknown sourceb. Significant change in the residents' physical/emotional/ mental conditionc. Need to transfer the resident to a hospital/treatment centerd. Specific instructions to notify the physician of changes in resident's condition. e. In addition to notifying the residents and /or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition or status. During a review of the facility's policy and procedure (P&P) titled, Transfer or discharge dated 8/2018, indicated transfers or discharges may be necessary to protect the health and well-being of the residents:a. If the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. The facility will notify the resident's attending physician for transfer to the hospital for treatmentc. Notify the receiving facility that the transfer is being maded. Notify the representative or family member. Event ID: Facility ID: 056043 If continuation sheet Page 5 of 5