Health inspection·May 6, 2025

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 an extended floor mattress (a thicker safety mat [a floor pad designed to help prevent injury should a person fall] designed to provide cushion and protection in the event of a fall) was placed on the floor next to the bed for one of three sampled residents (Resident 1) who was assessed at high risk for falls and who had a history of falling, per Resident 1 ' s Care Plan dated 3/5/2025 This deficient practice resulted in Resident 1 experiencing an unwitnessed fall (4/25/2025) and being found on the floor without an extended floor mattress in place as care planned (3/5/2025). This deficient practice had the potential to result in Resident 1 sustaining aninjury. Findings During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body). During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/2/2025, the MDS indicated Resident 1 ' s cognition (the process of knowing, understanding, and thinking) was severely impaired and Resident 1 required substantial/maximal assistance (helper does more than half the effort) from facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1 ' s Care Plan revised 3/5/2025, the Care Plan indicated Resident 1 had a fall on 3/4/2025. The Care Plan ' s goals included Resident 1 would resume usual activities without further incident. The Care Plan ' s interventions included using an extended mattress on the floor due to Resident 1 ' s history of falls. During a review of Resident 1 ' s Nurses Notes dated 4/25/2025, the Nurses ' Notes indicated licensed staff responded to Resident 1 ' s bed alarm and found Resident 1 lying on the floor on the right side of her bed. The Nurses Notes indicated there was no extended mattress on the floor on the right side of Resident 1 ' s bed because of Resident 2 ' s (Resident 1 ' s roommate) safety precautions to keep the room and [ During an interview on 5/6/2025 at 12:58 p.m., Licensed Vocational Nurse (LVN) 1 stated the extended floor mattress could not be placed on the floor on the right side of Resident 1 ' s bed because (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: 056283 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 056283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bixby Towers Post-Acute Rehab 3747 Atlantic Avenue Long Beach, CA 90807 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)