Health inspection·July 3, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician when one of four sampled resident's (Resident 1) laboratory (lab) result dated 5/22/2025 indicated a high blood glucose (sugar) level, a low sodium (the electrolyte in the body crucial for maintaining fluid balance, nerve and muscle function, and blood pressure) level, and a low chloride (an essential electrolyte that plays a crucial role in body fluids, including blood, sweat and urine) level. This deficient practice resulted in Resident 1's physician being unaware of Resident 1's abnormal lab results and a delay in care and treatment. 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] with diagnosis including Chronic Obstructive Pulmonary Disease ([COPD] a progressive lung disease characterized by persistent airflow limitation and breathing problems) and DM. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 was able to make decisions that were consistent and reasonable, required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities]) such as bathing, dressing, personal hygiene and toileting a person performs daily to care for themselves), and was incontinent (involuntary voiding of urine and stool) of bladder and bowel functions.During a review of Resident 1's Change of Condition (COC) form, dated 5/15/2025 and timed at 6:16 p.m., the COC indicated Resident 1 had increased confusion and was not eating well. The COC indicated Resident 1's physician ordered a complete blood count ([CBC] a blood test that analyzes the different types of cells in the blood), a basic metabolic panel ([BMP] a blood test that measures several substances in the blood to assess a person's overall health and organ function including b/s) and a UA with a culture and sensitivity ([C&S] a diagnostic lab procedure used to identify the type of bacteria and to determine which medication can successfully fight an infection). During a review of Resident 1's Physician's Order, dated 5/16/2025, the Physician's Order indicated to obtain a CBC, BMP and UA with a C&S due to Resident 1's increased confusion and poor food intake.During a review of Resident 1's Lab Results Report, the Lab Results Report indicated on 5/16/2025, a glucose level of 378 milligrams (mg)/deciliter (dl), with a normal range of 85 mg/dl to 125 mg/dl.During a review of Resident 1's Nursing Progress Note dated 5/19/2025 and timed at 4:25 p.m., the Nursing Progress Note indicated Resident 1's physician was made aware of Resident 1's lab results dated 5/16/2025 and a Comprehensive Metabolic Panel ([CMP] a group of blood tests that provides a broad overview of the body's chemical balance and metabolism including the kidney and liver function, blood sugar and electrolyte levels) was ordered on 5/22/2025.During a review of Resident 1's Lab Results Report dated 5/22/2025, the Lab Results Report indicated a glucose level of 362 mg/dl, a sodium level of 130 millimoles(mmol)/Liter(L) (with a normal range of 136 mmol/L to 145 mmol/L), and a chloride level of 93 mmol/L (with a normal range of 98 mmol/L to 107 mmol/L).During a review of Resident 1's Clinical Record Page 1 of 13 056150 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in 5/2025, there was no documented evidence that Resident 1's lab results dated 5/22/2025 were reported to Resident 1's Physician. During an interview on 7/3/2025 at 5:26 p.m., the Director of Nursing (DON) stated Resident 1's physician should have been notified of Resident 1's abnormal labs. During a telephone interview on 7/3/2025 at 7:45 p.m., Resident 1's physician stated he was not notified of Resident 1's lab results dated 5/22/2025 and had he been aware he could have ordered accu-checks (a brand of b/s monitoring systems used by people with DM to measure their b/s levels) to monitor Resident 1's b/s. Resident 1's physician stated managing Resident 1's DM and b/s levels was important to prevent complications of DMDuring a review of the facility's P/P titled, Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notifications dated 12/17/2024, the P/P indicated the facility shall promptly notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of the residents' lab results that fall outside of the clinical reference ranges because delayed notification can contribute to delays in changing the course of treatment or care plan. 056150 Page 2 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Care Plan was created one of four sampled residents (Resident 1) who was administered Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia [a condition where there's too much sugar in the bloodstream]) with intervention to monitor Resident 1 for risk, side effects, and adverse reactions related to the use of Prednisone due to this medications ability to increase blood sugar (b/s) levels. This deficient practice resulted in Resident 1's b/s level not being monitored from 4/11/2025 through 5/16/2025 to ensure it was within an acceptable range in order to provide care and treatment accordingly. On 6/22/2025 Resident 1 was transferred to a General Acute Care Hospital (GACH) due to an altered level of consciousness ([ALOC] a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe changes like a coma [a deep state of unconsciousness where a person is unresponsive to external forces and cannot be awakened]), hypotension (low blood pressure [BP]), a high heart rate (HR), and a b/s level that indicated high (when the b/s level is too high to register) on the facility's glucometer (a machine that measures the concentration of glucose or blood sugar in a small sample of blood). At the GACH Resident 1's b/s level was 1060 milligrams([mg] metric unit of measurement, used for medication dosage and/or amount)/deciliter([dl] a unit of measurement) and she was diagnosed with diabetic ketoacidosis ([DKA] a life-threatening complication of DM where the body produces too many acidic chemicals called ketones [a byproduct of fat breakdown]) with coma associated with DM hyperosmolar hyperglycemic state ([HHS] a serious life threatening complication of DM characterized by extremely high b/s and severe dehydration). Resident 1 was admitted to the GACH's Intensive Care Unit ([ICU] a specialized unit in the hospital that provides specialized treatment and monitoring for critically ill patients) in critical condition.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] with diagnosis including Chronic Obstructive Pulmonary Disease ([COPD] a progressive lung disease characterized by persistent airflow limitation and breathing problems) and DM. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 was able to make decisions that were consistent and reasonable, required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities]) such as bathing, dressing, personal hygiene and toileting a person performs daily to care for themselves), and was incontinent (involuntary voiding of urine and stool) of bladder and bowel functions.During a review of Resident 1's Clinical Record (Care Plan section), the Clinical Record indicated there was no Care Plan created related to Resident 1's use of Prednisone or interventions to monitor Resident 1 for risk, side effects, or adverse reactions associated with the use of Prednisone due to this medication ability to increase blood sugar levels. During an interview and record review on 7/3/2025 at 12:09 p.m., Registered Nurse Supervisor (RNS) 3 stated a Care Plan should have been created related to Resident 1's use of Prednisone with interventions ensuring Resident 1's b/s was managed. During a review of the facility's Policy and Procedures (P/P), titled, Comprehensive Care Plans revised 2/5/2025, the P/P indicated the facility shall develop and implement a comprehensive person centered care plan for each resident after a comprehensive assessment, that includes measurable objectives and timeframes to meet the residents' medical, nursing, mental and psychosocial needs.During a review of the facility's P/P, titled, Unnecessary Drugs revised 2/5/2025, the P/P indicated the information during the initial and ongoing evaluation of the residents will be 056150 Page 3 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0656 Level of Harm - Minimal harm or potential for actual harm incorporated into the residents' comprehensive care plan that reflects person-centered medication related goals and parameters for monitoring the resident's condition, including the likely medication effects and potential adverse consequences. Residents Affected - Few 056150 Page 4 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that licensed nurses monitored the blood sugar (b/s) levels for one of four sampled residents (Resident 1) who had diagnosis of diabetes mellitus ([DM] disease characterized by elevated levels of blood sugar) and was receiving Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia (a condition where there's too much sugar in the bloodstream). The facility failed to:1. Ensure licensed nurses clarified with Resident 1's physician, instructions from the admitting GACH to check Resident 1's b/s levels every day before meals and at bedtime and to take diabetic medication or insulin (a medication used to manage b/s levels in people with DM) as prescribed. 2. Ensure Resident 1's b/s levels were monitored due to diagnosis of DM and use of Prednisone, from 4/11/2025 through 5/16/2025. 3. Ensure Resident 1's physician provided instructions for care, interventions and/or treatment to manage Resident 1's abnormal (high) blood and urine glucose (sugar) levels when Resident 1's b/s level of 378 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount)/deciliter ([dl] a unit of measurement) (reference range of 85 mg/dl to 125 mg/dl) was obtained via a lab report on 5/16/2025, a glucose level of more than a 1,000 mg/dl, was obtained from a urinalysis ([UA] urine test [reference range is negative]) on 5/21/2025, and a b/s level of 362 mg/dl was obtained via a lab report on 5/22/2025. 4. Notify Resident 1's physician of the resident's high b/s level of 362 mg/dl based on blood lab test report dated 5/22/2025 to obtain instructions for care, interventions and/or treatment. 5. Follow Resident 1's untitled Care Plan for DM dated 5/10/2025, to monitor Resident 1 for signs and symptoms (s/s) of hyperglycemia (high b/s level above 180 mg/dL two hours after eating and fasting blood glucose levels above 125 mg/dL) and hypoglycemia (low b/s level below 70 mg/dl) by checking (via a Glucometer [a machine that measures the concentration of glucose or blood sugar in a small sample of blood) Resident 1's b/s levels and rechecking as needed. 6. Develop a Care Plan for the use of Prednisone with interventions to monitor Resident 1 for risk, side effects, adverse reactions related to the use of Prednisone. 7. Follow the facility's Policy and Procedure (P/P) titled, Processing Physician Orders that indicated to process the physician orders and to clarify these orders with the attending physician to verify and maintain the accuracy of the physician orders to provide appropriate care and services. 8. Follow the facility's P/P titled, Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notifications that indicated the facility shall promptly notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of the residents' lab results that fall outside of the clinical reference ranges because delayed notification can contribute to delays in changing the course of treatment or care plan.9. Follow the facility's P/P titled, Diabetes Management Policy that indicated the facility shall maintain the highest level of function of the residents within the normal limitations of the disease. The primary care physician orders should address medication and laboratory tests. Every resident with the diagnosis of diabetes mellitus will be identified and their care provided based on their assessed problems. Every resident should be watched for signs and symptoms of hyperglycemia and hypoglycemia including but not limited to visual disturbances, loss of skin integrity, and dehydration and should be reported to the primary care physician.These deficient practices resulted in Resident 1's b/s level not being monitored from 4/11/2025 through 5/16/2025 to ensure it was within an acceptable range in order to provide care and treatment accordingly. On 6/22/2025 Resident 1 was transferred to a GACH due to an altered level of consciousness ([ALOC] a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe Residents Affected - Few 056150 Page 5 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0684 Level of Harm - Actual harm Residents Affected - Few changes like coma), hypotension (low blood pressure [BP]) a high heart rate (HR), and a b/s level that indicated high (when the b/s level is too high to register) on the facility's glucometer. At the GACH Resident 1's b/s level was 1060 mg/dl and the resident was diagnosed with diabetic ketoacidosis ([DKA] a life-threatening complication of DM where the body produces too many acidic chemicals called ketones) with coma (a deep state of unconsciousness where a person is unresponsive to external forces and cannot be awakened) associated with DM hyperosmolar hyperglycemic state ([HHS] a serious life threatening complication of DM characterized by extremely high b/s and severe dehydration), sepsis (a life threatening condition that occurs when the body's immune system overreacts to an infection) due to urinary tract infection ([UTI] an infection of the urinary system that includes kidneys, ureters, bladder and urethra), and candidiasis (a fungal infection caused by an overgrowth of yeast that can occur in various parts of the body including the mouth, vagina, skin and even inside the body) of the urogenital site (a region of the body that composes of the urinary system and the reproductive system). Resident 1 was admitted to the GACH's Intensive Care Unit ([ICU] a specialized unit in the hospital that provides specialized treatment and monitoring for critically ill patients) in critical condition.Findings:During a review of Resident 1's Preadmission Report from the GACH dated 4/11/2025 and timed at 4:51 p.m., the Preadmission Report indicated Resident 1's glucose levels were routinely checked with Lispro (a type of insulin, dosage not indicated) coverage. During a review of the GACH's Reconciled Home Medications and Discharge Instructions dated 4/11/2025 and timed 3:18 p.m., the Reconciled Home Medications and Discharge Instructions indicated Resident 1 was to begin taking Prednisone 20 mg two tablets (40 mg), two times a day, DM medication and/or insulin, to ensure management of her DM. The Reconciled Home Medications and Discharge Instructions indicated a recommendation for Resident 1 to follow up with her primary care physician for b/s checks before meals and at bedtime and to inform Resident 1's physician if she showed s/s of hyperglycemia and hypoglycemia that included b/s levels over 300 mg/dl or b/s levels of less than 70 mg/dl. During a review of Resident 1's Physician's Order Summary Report, the Physician's Order Summary Report indicated the following orders:1. On 4/11/2025 - Prednisone 20 mg two tablets, two times a day for COPD. 2. On 5/10/2025 - Monitor s/s of hypoglycemia and hyperglycemia every shift and check/recheck Resident 1's b/s as needed.During a review of Resident 1's Clinical Record, the Clinical Record indicated no evidence that DM medication or insulin was prescribed and/or administered to Resident 1 from her admission to the facility on 4/11/2025. During a review of Resident 1's Medication Administration Records ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/2025, 5/2025 and 6/2025, the MARs indicated the following:1. In April 2025 Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 37 doses.2. In May 2025 Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 59 doses.3. In June 2025 Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 41 doses.During a review of Resident 1's MARs dated 4/2025, 5/2025 and 6/2025, the MARs indicated no documented evidence that Resident 1's b/s was checked.During a review of Resident 1's Care Plans in the resident's Clinical Record, the Clinical Record indicated there was no Care Plan created related to Resident 1's use of Prednisone or interventions to monitor Resident 1 for risk, side effects, or adverse reactions associated with the use of Prednisone due to this medication ability to increase blood sugar levels. According to the Nationally recognized Cleveland Clinic, Prednisone may increase blood sugar characterized by increased thirst or amount of urine, unusual weakness or fatigue, blurry vision.https://my.clevelandclinic.org/health/drugs/20469-prednisone-tabletsDuring a review of Resident 1's untitled Care Plan dated 5/10/2025, the Care Plan indicated Resident 1 had a diagnosis of DM. The 056150 Page 6 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0684 Level of Harm - Actual harm Residents Affected - Few Care Plan's goals indicated Resident 1 would be free from any s/s of hyperglycemia and hypoglycemia and would have no complications related to DM. The Care Plans interventions included monitoring Resident 1 for s/s of hyperglycemia and hypoglycemia by checking and rechecking Resident 1's b/s levels as needed, reporting to Resident 1's physician s/s of hyperglycemia including increased thirst/appetite, fatigue, and stupor (a condition of being extremely drowsy, almost unconscious like being in a deep sleep). During a review of Resident 1's Change of Condition (COC) form , dated 5/15/2025 and timed at 6:16 p.m., the COC indicated Resident 1 had increased confusion and was not eating well. The COC indicated Resident 1's physician ordered a complete blood count ([CBC] a blood test that analyzes the different types of cells in the blood), a basic metabolic panel ([BMP] a blood test that measures several substances in the blood to assess a person's overall health and organ function including b/s) and a UA with a culture and sensitivity ([C&S] a diagnostic lab procedure used to identify the type of bacteria and to determine which medication can successfully fight an infection). During a review of Resident 1's Physician's Order, dated 5/16/2025, the Physician's Order indicated to obtain a CBC, BMP and UA with a C&S due to Resident 1's increased confusion and poor food intake.During a review of Resident 1's Lab Result Report dated 5/16/2025, the Lab Result Report indicated Resident 1's b/s level was 378 mg/dl. During a review of Resident 1's UA with C&S dated 5/21/2025, the UA with C&S indicated a glucose level of more than 1,000 mg/dl in Resident 1's urine. During a review of Resident 1's Comprehensive Metabolic Panel [CMP] a group of blood tests that provides a broad overview of the body's chemical balance and metabolism including the kidney and liver function, blood sugar and electrolyte levels) test dated 5/22/2025, the CMP indicated Resident 1's b/s level was 362 mg/dl. During a review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) COC 911 Transfer Form dated 6/22/2025 and timed at 10:14 a.m., the SBAR COC 911 Transfer Form indicated Resident 1 was transferred to a GACH because of hyperglycemia. The SBAR COC 911 Transfer Form indicated Resident 1 had decreased consciousness and only responded to tactile stimuli (direct physical contact to produce sensations of pain, pressure, vibration, temperature and pain), the resident's breathing was labored (a manner of using more effort and energy to breathe than is typical) and rapid (a breathing rate or manner that is faster than normal for a person's age and activity level), the resident was diaphoretic (excessive sweating) with s/s of thirst and fatigue. The SBAR COC 911 Transfer Form indicated Resident 1's heart rate [HR] reference range of 60 to 100 beats per minute [bpm]) was 115, respiratory rate [(RR] reference range of 12 to 20 breaths per minute) was 26, blood pressure ([BP] reference range 120/80 millimeters of mercury (mmhg) was 70/89 mmhg, and the oxygen saturation rate ([O2 sat] a measurement of how much oxygen the blood is carrying as a percentage, reference range of 95%-100%) was of 95% while receiving supplemental oxygen via a nasal cannula (a thin tube with two small prongs that fit into a patient's nostrils to deliver supplemental oxygen). Oxygen delivery flow was not indicated. The SBAR COC 911 Transfer Form indicated Resident 1's b/s level was High. During a review of the GACH's Emergency Provider Note (ED Note) dated 6/22/2025 and timed at 11:08 a.m., the ED Note indicated Resident 1 presented in the emergency room with an altered mental status ([AMS] any noticeable change in a person's level of awareness, cognition, or behavior) and low blood pressure. The ED Note indicated Resident 1 was nonverbal with a Glasgow coma score (a neurological (related to the nervous system [brain, spinal cord, and nerves]) assessment used to determine a person's level of consciousness which assesses the key areas such as eye opening, verbal response and motor response, ranging from zero to 15) of eight (indicating the patient is in a coma with limited or no response to external stimuli), HR of 133 bpm, and a RR of 35 breaths per minute. The ED 056150 Page 7 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0684 Level of Harm - Actual harm Residents Affected - Few Note indicated the following lab results: 1. Blood Ph (the measure of blood acidity) of 7.19 (normal range is 7.35 to 7.45. 7.19 is a significant indicator of DKA).2. [NAME] Blood Count ([WBC] a blood test that measures the number of white blood cells in blood, reference range of 4,500 k/uL to 11,000 k/uL) of 20.8 kilounits/liter (k/uL). An elevated WBC can signify various conditions, including DKA. 3. Glucose level of 1,060 mg/dl in urine.4. Bicarbonate level (a blood test that measure a form of natural waste) of 12 millimole ([mmol] a unit of measurement for the amount of a substance) (Reference range of 21 to 32 mmol per liter. A low bicarbonate level is a key indicator of DKA).5. Anion gap (a blood test used to indicate electrolyte [minerals that carry an electrical charge when dissolved in body] imbalances) of 30 milliequivalents/liter (mEq/L) (Reference range of 5 mEq/L to 14 mEq/L. A high anion gap with high b/s levels is often indicative of DKA) 6. Troponin (protein found in the heart muscle) level (a blood test used to indicated damage to the heart muscle) of 106 nanograms/liter (ng/L) (Reference range of 0 to 54 ng/L. High troponin levels indicate injury or damage to the heart muscle and can be elevated in conditions such as hyperglycemia) 7. Lactate level (a blood test used to indicate the if the body is producing enough O2 or if there is an underlying medical condition) of 4.4 mmol/L (Referfence range of 0.9 mmol/L to 1.7 mmol/L. Severe hyperglycemia can lead to increased lactate).During a review of the ED Note dated 6/22/2025, the ED Note indicated Resident 1 was given a bolus (a large single dose) of intravenous ([IV] in the vein) fluids, IV antibiotics (medication used to treat infections) and IV insulin. The ED Note indicated Resident 1 had DKA with coma associated with type two DM HHS, sepsis due to UTI, candidiasis of the urogenital site and was admitted to the ICU in serious and/or critical condition.During a telephone interview on 7/1/2025 at 4:44 p.m., Licensed Vocational Nurse (LVN) 3 stated Resident 1 was admitted to the facility on [DATE] from the GACH with a Preadmission Report, a Reconciled Home Medication form, and Discharge Instructions. During a subsequent interview with LVN 3 on 7/3/2025 at 3:44 p.m., LVN 3 stated he called Resident 1's physician on 4/11/2025 to get approval for the list of medications that accompanied Resident 1 on admission to the facility and Resident 1's physician instructed him to continue all previously administered medication from the GACH. LVN 3 stated he did not notify Resident 1's physician of the GACH's discharge instructions to check Resident 1's b/s and he did not ask Resident 1's physician if he wanted Resident 1 to take diabetic medication and/or insulin. During a telephone interview on 7/2/2025 at 11:35 a.m., Resident 1's Family Member (FM) stated he often visited Resident 1 at the facility when he got off work and Resident 1 was usually alert and interactive with him. The FM stated on 5/15/2025, he noticed Resident 1 was more confused and would drift off to sleep during a conversation. The FM stated he told the licensed nursing staff at the facility to call Resident 1's physician to obtain an order to check Resident 1's labs and urine and evaluate Resident 1's medications. The FM stated on 6/16/2025 during the morning (time unknown), he visited Resident 1, and she appeared to be weaker, she looked sedated (in a calm, almost dreamlike state, but still somewhat aware of the surroundings), she could barely open her eyes and her speech was slurred. The FM stated Resident 1 was not doing very well in the ICU at GACH and when she was transferred from the GACH to a different facility on6/26/2025 she remained non-verbal and never woke up when he visited her there. The FM stated he was concerned that Resident 1 would not make it (recover) because her (Resident 1) condition was not good. During an interview on 7/2/2025 at 2:02 p.m., Certified Nursing Assistant (CNA) 3 stated she usually took care of Resident 1 and Resident 1 was able to verbalize her needs and interact with staff and family from 4/2025 through the first week of 5/2025. CNA 3 stated in the middle of 5/2025, Resident 1 was always thirsty and asking for more ice and water. CNA 3 stated Resident 1 began to sleep more than usual and had to be woken up in order to complete her ADLs. CNA 3 stated on 056150 Page 8 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0684 Level of Harm - Actual harm Residents Affected - Few 6/22/2025 at 7:30 a.m., she tried to wake Resident 1 up so she could eat breakfast but Resident 1 was very sleepy and would attempt to open her eyes and moved her hands towards her (CNA 3) as if she wanted to do something or say something to her. CNA 3 stated she came back to check on Resident 1 at 8:10 a.m. and noticed Resident 1 had not eaten any of her food. CNA 3 stated Resident 1 tried to open her eyes and tell her something but was too weak and went back to sleep. CNA 3 stated at 9 a.m., she went to recheck Resident 1, and she (Resident 1) would not answer any questions. CNA 3 stated she called the charge nurse (LVN 6) and when LVN 6 checked Resident 1, she (CNA 3) heard LVN 6 saying Resident 1's b/s was high, and the paramedics had to be called.During a telephone interview on 7/2/2025 at 2:31 p.m., LVN 6 stated earlier during the 7 a.m. to 3 p.m. shift on 6/22/2025 she observed that Resident 1 was lethargic (lacking energy and enthusiasm, feeling sluggish, slow and sleepy) and would not open her eyes when asked. LVN 6 stated, she checked Resident 1's vital signs ([v/s] measurements of the body's basic functions) and found that Resident 1 had low blood pressure of 70/89 mmHg and the glucometer indicated Resident 1's b/s was Hi. LVN 6 stated the paramedics were called and Resident 1 was transferred to the GACH. During an interview on 7/3/2025 at 5:26 p.m., the Director of Nursing (DON) stated it was the responsibility of the licensed nurses and the physician to ensure all residents were provided care.During a telephone interview on 7/3/2025 at 7:45 p.m., Resident 1's physician stated he and his team were aware of Resident 1's lab results on 5/16/2025. Resident 1's physician stated he was not notified of Resident 1's lab result dated 5/22/2025 when the resident's b/s was over 300 mg/dl and stated had he been aware he could have ordered accu-checks (a brand of b/s monitoring systems used by people with DM to measure their b/s levels) to monitor Resident 1's b/s. Resident 1's physician stated managing Resident 1's DM and b/s levels was important to prevent complications of diabetic ketoacidosis or HHS which could cause Resident 1's debility (a general state of weakness or feebleness) and/or death.During a review of the facility's policy and procedure (P/P) titled, Processing Physician Orders dated 8/2027, the P/P indicated it is practice of the facility to process the physician orders and to clarify these orders with the attending physician including communication of any system identified such as residents' allergies, contraindications as well as summary of residents' medical diagnosis, to verify and maintain accuracy of the physician orders to provide appropriate care and services, reduce medication related risks and comply with drug regimen review regulatory requirements.During a review of the facility's P/P titled, Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notifications dated 12/17/2024, the P/P indicated the facility shall promptly notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of the residents' lab results that fall outside of the clinical reference ranges because delayed notification can contribute to delays in changing the course of treatment or care plan.During a review of the facility's P/P titled, Diabetes Management Policy revised 2/5/2025, the P/P indicated the following:a. The facility shall maintain the highest level of function of the residents within the normal limitations of the diseaseb. The facility shall prevent the residents from any complications of the disease process and the primary care physician orders should address medication, diet, laboratory tests and special precautions if needed.c. Every resident with the diagnosis of diabetes mellitus will be identified and their care provided based on their assessed problems and areas to monitor shall be addressed in their care plan; andd. Every resident should be watched for signs and symptoms of hyperglycemia and hypoglycemia including but not limited to visual disturbances, loss of skin integrity, and dehydration and should be reported to the primary care physician. 056150 Page 9 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had an order for Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia (a condition where there's too much sugar in the bloodstream) 20 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) 2 tablets, twice a day (80 mg), had a stop date and/or duration of administration. This deficient practice resulted in Resident 1 taking Prednisone 20 mg., 2 tablets twice a day (for a total of 80 mg daily), from 4/12/2025 until 6/22/2025. Resident 1 had a change of condition (COC) and was transferred via 911 to a GACH on 6/22/2025, due to an altered level of consciousness (a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe changes like coma), hypotension (low blood pressure where the normal range is less than 120 systolic [top number] and less than 80 [bottom number]), and a blood sugar (b/s) level of high (the b/s was too elevated to register, reference range of 70 mg/deciliter ([dl] a unit of volume) to 99 mg/dl, obtained from a glucometer (a machine that measures the concentration of glucose or blood sugar in a small sample of blood) Resident 1's b/s at the GACH was 1060 mg/dl and she was admitted to the GACH's Intensive Care Unit ([ICU] a specialized unit in the hospital that provides specialized treatment and monitoring for critically ill patients) comatose (a deep state of unconsciousness where a person is unresponsive to external forces and cannot be awakened) with Diabetic Ketoacidosis (a life-threatening complication of DM where the body produces too many acidic chemicals called ketones [a product of fat breakdown]) associated with type 2 DM hyperosmolar hyperglycemic [NAME] ([HsHS] a serious, life threatening complication of diabetes). 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] with diagnosis including Chronic Obstructive Pulmonary Disease ([COPD] a progressive lung disease characterized by persistent airflow limitation and breathing problems) and DM. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 was able to make decisions that were consistent and reasonable, required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities]) such as bathing, dressing, personal hygiene and toileting a person performs daily to care for themselves), and was incontinent (involuntary voiding of urine and stool) of bladder and bowel functions.During a review of Resident 1's Order Summary Report (Physician's Orders), the Physician's Order indicated on 4/11/2025, an order for Prednisone 20 mg two tablets two times a day, with no stop date or duration of treatment.During a review of Resident 1's Medication Administration Records ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/2025, 5/2025 and 6/2025, the MARs indicated the following:1. In April 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 37 doses.2. In May 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 59 doses.3. In June 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 41 doses.During a telephone interview on 7/1/2025 at 4:44 p.m., Licensed Vocational Nurse (LVN) 3 stated Resident 1 was admitted to the facility on [DATE] from a GACH with a Preadmission Report, a Reconciled Home Medication form, and Discharge Instructions. During a subsequent interview with LVN 3 on 7/3/2025 at 3:44 p.m., LVN 3 stated he called Resident 1's physician on 4/11/2025 to get approval for the list of medications that accompanied Resident 1 on admission to the facility and Resident 1's physician 056150 Page 10 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few instructed him to continue all previously administered medication from the GACH, which included the Prednisone. LVN 3 stated the Prednisone had no stop date and he should have clarified with Resident 1's physician about a stop date for the Prednisone. During a telephone interview on 7/2/2025 at 11:35 a.m., Resident 1's Family Member (FM) stated he often visited Resident 1 at the facility when he got off work and Resident 1 was usually alert and interactive with him. The FM stated on 5/15/2025, he noticed Resident 1 was more confused and would drift off to sleep during a conversation. The FM stated he told the licensed nursing staff at the facility to call Resident 1's physician to obtain an order to check Resident 1's labs and urine and evaluate Resident 1's medications. The FM stated on 6/16/2025 during the morning (time unknown), when he visited Resident 1, she appeared to be weaker, she looked sedated (in a calm, almost dreamlike state, but still somewhat aware of the surroundings), she could barely open her eyes, and her speech was slurred. The FM stated Resident 1 was not doing very well in the ICU at GACH and when she was transferred from the GACH to a different facility on 6/26/2025 she remained non-verbal and never woke up. During a telephone interview on 7/3/2025 at 3:23 p.m., the facility's Pharmacy Consultant (PC) stated Prednisone can be used long term, but the dose should be tapered (gradually reduced) down to 10 mg - 20 mg daily. The PC stated Resident 1's physician should have assessed Resident 1 regularly to determine if the dose of Prednisone Resident 1 was receiving was appropriate. During a telephone interview on 7/3/2025 at 7:45 p.m., Resident 1's Physician stated he was not aware that Resident 1's Prednisone had no stop date. Resident 1's Physician stated he could have tapered the dose Prednisone with a goal of discontinuing it because the dose Resident 1 was receiving was high and not necessary. During a review of the facility's Policy and Procedures (P/P), titled, Unnecessary Drugs revised 2/5/2025, the P/P indicated the facility shall ensure that the residents' entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs by:1. Initiating, maintaining, or discontinuing medication(s) by evaluating the resident's physical, behavioral, mental and psychological signs and symptoms in order to identify and rule out any underlying conditions, including the assessment of relative risks and benefits, and preferences and goals for treatment2. Identifying circumstances that warrant evaluation of the residents' underlying medical condition and medication(s) that include admission, readmission , a new or worsening change in condition/status3. Ensuring the attending physician of the residents assume leadership in medication management by developing, monitoring and modifying the medication regimen in collaboration with the residents and/or representatives, other professionals and the interdisciplinary team to take into consideration the dose, duration of use, indications and clinical need for medication and adequate monitoring for efficacy and adverse consequences, prevention, identifying and responding to adverse consequences. 056150 Page 11 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 ensure a Medication Regimen Review (MRR) for one of four sampled residents (Resident 1) was conducted in 6/2025. They failed to ensure a MRR conducted in 5/2025 with a recommendation by the facility's Pharmacist Consultant (PC) to add a duration of time for the use of Prednisone (medication used to treat a wide range of conditions[b/s] levels) was followed, by notifying Resident 1's physician of the PC's recommendation and ensuring Resident 1's physician responded.This deficient practice resulted in Resident 1's use and dosage of Prednisone not being evaluated per the PC's recommendation from 4/12/2025 until 6/22/2025. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 6/22/2025 due to an altered level of consciousness ([ALOC] a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe changes like coma [a deep state of unconsciousness where a person is unresponsive to external forces and cannot be awakened]), hypotension (low blood pressure [BP]), a high heart rate (HR), and a b/s level that indicated high (when the b/s level is too high to register) on the facility's glucometer (a machine that measures the concentration of glucose or blood sugar in a small sample of blood). At the GACH Resident 1's b/s level was 1060 milligrams([mg] metric unit of measurement, used for medication dosage and/or amount)/deciliter([dl] a unit of measurement) and she was diagnosed with diabetic ketoacidosis ([DKA] a life-threatening complication of DM where the body produces too many acidic chemicals called ketones [a byproduct of fat breakdown]) with coma associated with DM hyperosmolar hyperglycemic state ([HHS] a serious life threatening complication of DM characterized by extremely high b/s and severe dehydration). Resident 1 was admitted to the GACH's Intensive Care Unit ([ICU] a specialized unit in the hospital that provides specialized treatment and monitoring for critically ill patients) in critical condition.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] with diagnosis including chronic obstructive pulmonary disease ([COPD] a progressive lung disease characterized by persistent airflow limitation and breathing problems) and DM. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 was able to make decisions that were consistent and reasonable, required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities]) such as bathing, dressing, personal hygiene and toileting a person performs daily to care for themselves), and was incontinent (involuntary voiding of urine and stool) of bladder and bowel functions.During a review of Resident 1's Order Summary Report (Physician's Order), dated 4/11/2025, the Physician's Order indicated Prednisone 20 mg, two tablets, two times a day, without a stop date or duration of administration. During a review of Resident 1's Medication Administration Records ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/2025, 5/2025 and 6/2025, the MARs indicated the following:1. In April 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 37 doses.2. In May 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 59 doses.3. In June 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 41 doses.During a review of the facility's Consultant Pharmacist's Medication Regimen Review dated 5/1/2025 to 5/9/2025, the Consultant's Pharmacist's Medication Regimen Review indicated a recommendation for the facility to obtain a duration for the use of Prednisone.During a review of Resident 1's Clinical Record for 5/2025, the Clinical Record indicated there was no documented evidence that the PC's recommendation was followed. During a telephone interview on 7/3/2025 at 3:23 p.m., the PC Residents Affected - Few 056150 Page 12 of 13 056150 07/03/2025 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the MRR is conducted monthly and is crucial in identifying residents' medication irregularities. The PC stated he was not the PC who conducted the MRR in 5/2025, but the PC's recommendation made in 5/2025 should have been conveyed to Resident 1's physician prevent unnecessary medication administration. During a telephone interview on 7/3/2025 at 7:45 p.m., Resident 1's Physician stated he was not aware that Resident 1's Prednisone had no stop date or duration for use, and he was not notified of the facility's PC's recommendation to add a duration for use. During an interview on 7/3//2025 at 5:26 p.m., the Director of Nursing (DON) stated she was not the DON at the time of the PC's recommendation, she was not aware of the recommendation or that it was completed. The DON stated, the DON at that time should have notified Resident 1's physician of the PC's recommendation so Resident 1's physician could have assessed Resident 1 and evaluated the use of the Prednisone based on the PC's recommendation. During a review of the facility's Policy and Procedure (P/P), titled, Medication Regimen Review revised 4/9/2025, the P/P indicated the facility shall ensure the drug regimen of each resident at the facility will be reviewed at least once a month for a thorough evaluation of the medication regimen of each resident, with the goal of promoting positive outcome and minimizing adverse consequences and potential risks associated with the medication. The P/P indicated the facility staff shall act upon all recommendations according to procedures for addressing the medication regimen review irregularities. 056150 Page 13 of 13