Health inspection·June 6, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 1's narcotic and hypnotic record (narcotic log) for Hydrocodone-Acetaminophen 10-325mg, dated from 5/19/25, to 6/5/2025, it was indicated that a total of 22 doses of Hydrocodone-Acetaminophen 10-325mg were dispensed during this period for Resident 1. During a concurrent observation and interview on 6/6/2025 at 11:55 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that staff retrieved the 10-325mg tablets to administer the ordered dose of Hydrocodone-Acetaminophen 5-325mg. He was uncertain whether the entire 10-325mg tablet was administered or if the tablets were cut, as there was no documentation indicating the tablets were split, nor that the unused portions were properly discarded each time. LVN 2 also mentioned that the medication could not be cut. He stated that there had been a discrepancy between the physician's order and medication available and being pulled for administration for the past few weeks. During an interview on 6/6/2025 at 2:00 p.m. with Resident 1, Resident 1 stated that she had taken the whole table of Hydrocodone-Acetaminophen without cutting it, including the day before the observation. During an interview on 6/6/2025 at 4:12 p.m., the Director of Nursing stated that staff must follow physicians' orders for residents. During a review of the facility's policy and procedure (P&P) titled, administering pain medications, revised 10/2010, the P&P indicated that staff have to administer pain medications as ordered, document the following in the resident's medical record: medication and dose. The P&P also indicated that residents are not at risk for addition to narcotic analgesics if used as prescribed for moderate to severe pain. b. During a concurrent observation and interview conducted on 6/6/2025, at 10:35 a.m. with the Assistant Director of Nursing (ADON) in the East medication room, a narcotic container labeled 'Narcotic only' was observed in an unlocked refrigerator. Inside, there was one unopened 30 milliliter (ml-unit dose) bottle of Lorazepam Intensol for Resident 2. The ADON stated that they believed it was unnecessary to lock the narcotic container since the refrigerator itself was locked. During an interview on 6/6/2025 at 2:30 p.m., Licensed Vocational Nurse (LVN) 1 stated that Lorazepam Intensol, a controlled narcotic medication, requires a lock to limit access to assigned staff, preventing theft. During an interview on 6/6/ 2025, at 4:12 p.m. with the Director of Nursing (DON), the DON stated that staff should lock the narcotic medication cart or container because the medications are controlled substances. During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, revised 12/2012, the P&P indicated that controlled substances must be stored in the medication room in a locked container separate from containers for any non-controlled medications. This container must always remain locked, except when it is accessed to obtain medications for residents. The P&P also stated that the charge nurse on duty will maintain the keys to controlled substance containers. c. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/28/2022 and readmitted on [DATE] with diagnoses including functional quadriplegia(someone is completely unable to move their arms and legs, not because of a spinal cord injury, but because of a severe medical condition that makes it impossible for them to move or control their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 2 of 3 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 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some body) and encounter for palliative care (specialized care that focuses on improving the quality of life for people facing serious illness, both physically and emotionally). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 5/6/2025, indicated, Resident 2's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was severely impaired. The MDS indicated, Resident 2 was dependent with oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing, putting on/ taking off footwear and personal hygiene. During a review of Resident 2's Order Summary Report, dated 11/6/2024, the Order Summary Report indicated an order to give Lorazepam oral concentrate 0.25milliliter (ml-unit dose) by mouth every four hours as needed for anxiety manifested by agitation, restlessness for 14 days and the physician discontinued the Lorazepam order on 11/12/2024. During a concurrent observation and interview on 6/6/2025 at 10:35 a.m. with the Assistant Director of Nursing (ADON) in the East Medication room, one unopened 30ml bottle of Lorazepam Intensol was observed in the refrigerator for Resident 2. During a concurrent interview and record review on 6/6/2025 at 2:30 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's Order Summary, as of 6/6/2025 was reviewed. LVN 1 stated that the physician discontinued the lorazepam order in November 2024 and leaving no active order for Resident 2. LVN 1 stated that staff should have removed the lorazepam when it was discontinued six months ago. During an interview on 6/6/2025 at 4:12 p.m. The Director of Nursing (DON) stated that when a narcotic is discontinued, it should be properly removed from the premises to prevent it from being accidentally administered to a resident. During a review of the facility's P&P titled, Discarding and Destroying medications, revised 10/2014, the P&P indicated all unused controlled substances shall be retained in a securely locked are with restricted access until disposed of. During a review of the facility's P&P titled, Disposal of medications, syringes, and needleless, undated, the P&P indicated that unused doses of controlled substances wasted for any reason should be destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056164 If continuation sheet Page 3 of 3