Health inspection·September 4, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 one of three residents (Resident 1) and/or their responsible party (RP), was informed of the resident ' s transfer to another facility. Residents Affected - Few This failure resulted in violating the residents ' right to make an informed decision regarding the transfer to another facility. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted on [DATE] to the facility with diagnoses including dementia (loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities), cerebral infarction (an interruption in the flow of blood to cells in the brain), and mental and behavioral disorders (affect the way you think and behave). During a record review of Resident 1 ' s Minimum Data Set (MDS- standardized screening tool) dated 8/7/2024, the MDS indicated Resident 1 ' s cognitive (the ability to think, reason, and understood) skills for daily decision-making were moderately impaired. During a record review of Resident 1 ' s Informed Consent for Psychoactive Medication Treatment, dated 8/15/2024, the Informed Consent was obtained from Resident 1 ' s resident representative (daughter). During a record review of Resident 1 ' s Notice of Medicare Non-Coverage form (a notice that indicates when your care is set to end), dated 7/10/2024, The Confirmation of Notice by Telephone was completed by Resident 1 ' s resident representative. The notice states notification by telephone is done only in situations where the notice must be delivered to an enrollee in an institutionalized setting, who is unable to make decisions for him/herself. During a concurrent interview and record review of Resident 1 ' s medical record on 9/3/2024, at 10:05 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed the resident representative for Resident 1 was not notified that he was transferred to another facility. LVN 1 stated Resident 1 ' s resident representative should have been notified so their loved ones will know where they are and can be there when they arrive. During a concurrent interview and record review of Resident 1 ' s medical record on 9/3/2024 at 10:30 a.m., with the Director of Staff Development (DSD), the DSD stated when a resident is transferred, the family is notified so they are aware of where they are. DSD confirmed there was no (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: 555375 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 555375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Villa Post Acute 3232 E. Artesia Blvd. Long Beach, CA 90805 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)