Health inspection·January 29, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, Licensed Vocational Nurse (LVN) 1 failed to assess the mobility limitations and take precautions before moving one of three sampled residents (Resident 1), who was dependent on staff to roll from the left to the right side. The facility failed to ensure: LVN 1 requested assistance from another staff member before repositioning Resident 1, who per the Minimum Data Set ([MDS] a resident assessment tool), was dependent on staff to roll from the left side to the right and or the assistance of two or more helpers was required for Resident 1 to roll from the left to the right side. This deficient practice resulted in LVN 1 repositioning Resident 1 without assistance and hitting Resident 1's right knee on the resident's bed frame. Resident 1 experience pain, swelling and tenderness to the right knee, and was subsequently diagnosed with an acute (sudden-onset) right distal femur fracture (a break of the knee). Resident 1 was transferred to a General Acute Care Hospital (GACH) where the fractured knee was immobilized (to prevent from moving), she was treated for pain and monitored for bleeding and a thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included a closed fracture (broken bone that does not penetrate the skin) of lower end of right femur, dementia (a progressive state of decline in mental abilities), and Alzheimer's (disease characterized by a progressive decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 1's cognition (the ability to think and reason) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort, resident did none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on staff for rolling left to right. The MDS indicated Resident 1 had a functional limitation in range of motion ([ROM] the full, functional measurement of the distance and direction a joint can move, stretching from maximum bending to full straightening) to both of her upper (arms) and lower (legs) extremities. During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 1/2/2026, and timed at 9:30 p.m., the SBAR indicated during rounds LVN 1 observed Resident 1 at the edge of her bed, upon repositioning the resident, she (LVN 1) accidentally bumped Resident 1's knee against the resident's bed frame. The SBAR indicated Resident 1's knee was slightly swollen, tender to touch and Resident 1 was moaning with facial grimacing.During a review of Resident 1's Physician's Orders, dated 1/2/2026, and timed at 11:50 p.m., the Physician's Order indicated a STAT (immediate) radiology ([X-ray] a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) to Resident 1's bilateral (both sides) hips, right femur and right knee due to pain. During a review of (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 2 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 01/29/2026 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)