Health inspection·January 27, 2025

F 0555 Level of Harm - Minimal harm or potential for actual harm admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (any brain damage or disease that affects how the brain functions), cognitive communication deficit (a communication difficulty caused by a cognitive impairment), End Stage Renal Disease ([ESRD] irreversible kidney damage), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). Residents Affected - Few During a review of Resident 3 ' s H&P, dated 2/21/2024, the H&P indicated, Resident had the capacity to make decisions. During an interview on 1/24/ 2025, at 3:41 p.m., RP 2 stated he received a text and phone call on 11/12/2024 at 12:34 p.m. from the Social Worker Assistant (SSA) that Resident 3 would be assigned to another PCP (PCP 2). RP 2 stated she did not receive any documentation indicating the new PCPs contact information. 4. During a review of Resident 4 ' s Face Sheet, the Face Sheet indicated, Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including polyosteoarthritis (a type of inflammation that affects at least five joints at a time). The Face Sheet indicated Resident 4 was self-responsible. During an interview on 1/24/2025 at 4:13 p.m. Resident 4 stated, she did not receive anything in writing indicating the new PCP name and contact information. 5. During a review of Resident 5 ' s Face Sheet, the Face Sheet indicated, Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior). The Face Sheet indicated Resident 5 was self-responsible. During an interview on 1/24/2025 at 4:30 p.m., Resident 5 stated she did not make the request for her primary doctor (PCP 1) to be changed and was disappointed she was no longer going to receive care from him. Resident 5 stated she did not receive any documentation with the new PCP ' s contact information. During a concurrent interview and record review, on 1/24/2025, at 5:25 p.m., with Medical Records Director (MRD), the facsimile (FAX] communication technology that transmits printed material [like documents, images, or texts] from one location to another), dated 11/12/2024, was reviewed. The FAX indicated at 5:32 p.m., a FAX was sent to PCP 1 indicated his patients were assigned to PCP 2. During an interview on 1/27/2025 at 10:20 a.m., the Administrator (ADM) stated, he was notified by DON 2 that PCP 1 was very frustrated and stated he would not be returning to the facility and then PCP 1 left the building. The ADM stated he did not call PCP 1 to clarify what PCP 1 meant when he stated he wasn ' t coming back to the facility. The ADM stated he never received a phone call from PCP 1 and thought it was PCP 1 ' s responsibility to make a phone call to the facility, informing us that he was no longer going to return and to reassign his patients. The ADM stated PCP 1 ' s patients were then assigned to the Medical Director (MD) in the meantime until the Social Service Director (SSD) spoke to the residents and/or RPs informing them that PCP 1 would not be returning to the facility, of the physician change, and asked if the residents had a preference of physician in mind. If the resident didn ' t have a physician in mind, then PCP 2 was presented as an option. If PCP 1 wanted to come back, there is no reason why he would not be able to come back, and it would be up to the resident ' s if they would like to return under the care of PCP 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555375 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 555375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2025 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)

F 0555 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/27/2025, at 11:21 a.m., the MD stated he wasn ' t aware about PCP 1 leaving or why PCP 1 left the facility. During an interview on 1/27/2025, at 6:41 p.m., the Director of Nursing (DON 2) stated he overheard PCP 1 stating, I ' m not coming back. DON 2 stated he didn ' t clarify whether PCP 1 was not coming back that day, tomorrow, or not coming back to the facility at all. DON 2 stated PCP 1 did not say to assign his patients to another physician. DON 2 stated looking back, he should have clarified what PCP 1 meant when he stated he wasn ' t coming back. DON 2 stated he notified the ADM what PCP 1 stated but didn ' t notify the medical director. During a review of the facility ' s policy and procedure (P&P) titled, Choice of Attending Physician, dated 2001, the P&P indicated the resident is informed in writing of the name and contact information for his or her attending physician: any time the information changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555375 If continuation sheet Page 3 of 3