Health inspection·December 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 8/30/2024, the MDS indicated Resident 1 required substantial/maximal assistance (helper lifts or hold trunk of limbs and provides more than half the effort) with shower and bathing self, changing positions of lying to sitting on side of bed, and sit to lying. Resident 1 was dependent (resident does 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 transfers from one surface to another. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a communication tool used to share essential medial information) dated 8/20/2024 and timed at 7:10 p.m., the SBAR indicated at 6:00 p.m., Resident 1 came back from dialysis (a mechanical procedure to remove waste products and excess fluid from the blood when kidneys stop working properly) in stable condition. The SBAR indicated CNA 1 was transferring Resident 1 from his wheelchair to his bed when the resident fell. The SBAR indicated Resident 1 was found lying on his back and initially complained of left shoulder pain 7/10 on the pain scale (0 no pain, 10 worst possible pain). Resident was assisted back to bed with 4 staff members by a Mechanical Lift. During a review of the Radiology Notes dated 9/3/2024, the Radiology Notes indicated Resident 's Physician gave orders for a magnetic resonance imaging (MRI a noninvasive imaging technology that produces three dimensional images of the body) appointment scheduled at 1:00 p.m. MRI to the right shoulder to rule out rotator cuff tear (a tear in the tissues connecting muscle to bone around the shoulder joint. The Radiology Note indicated the appointment and transportation was schedule for 9/6/2024. During a review of Resident 1's Imaging Exam Report dated 9/6/2024 at 1:14 p.m., the MRI indicated a right shoulder nondisplaced fracture of the of the coracoid process (a hook- shaped bone on the shoulder blade that plays a key role in shoulder movement) and the distal clavicle (the end of the collar bone next to the shoulder) with swelling. During a record review of Resident 1's Occupational Therapy Evaluation and Plan of Treatment dated 9/11/2024 to 10/8/2024, the Occupational Therapy Evaluation notes indicated Resident 1's ROM to the right arm was Impaired (minimum Active Range of Motion (AROM, movement at a given joint when the person moves voluntarily)- assisted with someone's help due to fracture. Resident 1' s right upper extremity strength was 3/5 (the muscle is able to move against gravity and withstand a minimal amount of resistance). The Occupational Therapy Evaluation notes indicated Resident 1 was feeling a sharp pain even when not moving and increasing in intensity 5/10 with movement. During an interview on 12/2/2024 at 10:51 a.m., in Resident 1's room, Resident 1 stated on 8/20/ 2024 he arrived at the facility from dialysis. Resident 1 stated he told CNA 1 he needed help because he wanted to go to bed. Resident 1 stated CNA 1 placed him into the Mechanical Lift raised him high and he fell out on to the floor hitting his head. Resident 1 stated CNA 1 ran out of the room and LVN 1 came to help. Resident 1 stated 4 CNAs assisted in picking him up with the Mechanical Lift and placed him in bed. Resident 1 stated his right shoulder hurt so bad he did not want to be touched to be picked up. During an interview on 12/2/2024 at 11:27 a.m., Licensed Vocational Nurse 1 (LVN 1) stated she heard about Resident 1's fall and is familiar with the resident's care. LVN 1 stated when transferring Resident 1 in a Mechanical Lift two people need to assist, to have a safe environment for the resident during transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056234 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 056234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marlora Post Acute Rehab Hosp 3801 E Anaheim St 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 0689 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/2/2024 at 11:30 a.m., the Director of Staff Development (DSD) stated when using a Mechanical Lift there need to be two nurses present. The DSD stated the second person can guide the resident in the Mechanical Lift to prevent a fall. The DSD stated the nurses are not to lift a resident (general) in the Mechanical Lift without a second staff member being present to help. The DSD stated operating the Mechanical Lift alone to transfer a resident (general) can be dangerous for everyone. Residents Affected - Few During an interview on 12/2/2024 at 10:17 a.m., the Director of Nursing (DON), stated Resident 1 is a two person assist and there should have been two nurses assisting Resident 1 in the Mechanical Lift. The outcome can be injury because a Mechanical Lift cannot be controlled with just one person. During an interview on 12/2/2024 at 10:58 a.m., with the OT, the OT stated when she evaluated resident 1 on 9/11/2024 Resident 1 had right arm and shoulder limitation in ROM the resident could not raise his arm on his own or against gravity. The OT stated Resident 1 requires OT services to address his ability to use his right arm, after the fracture he sustained from the Mechanical Lift fall. The OT stated Resident 1 needs OT to return to his previous level of functioning and avoid declines in the use of his right arm. During a record review of the facility's policy and procedure (P/P), titled Mechanical Lift, revised October 2019, indicated a Mechanical Lift is used appropriately to facilitate transfers of residents. At least two people are present while the resident is being transferred with the Mechanical Lift. Mechanical Lifts are devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by nursing staff alone .nursing staff will receive training on how to use the Mechanical Lift .at least two people are present while resident is being transferred with the Mechanical Lift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056234 If continuation sheet Page 3 of 3