Health inspection·November 21, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Evaluation, dated 9/25/2025, indicated while in bed, Resident 1 attempted to stand up without assistance using the over the bed TV mount for support causing resident to fall and hit her forehead.During a review of Resident 1's Interdisciplinary Team ([IDT] team of healthcare professionals who work together to develop and implement a resident's care plan) note, dated 9/25/2025, the note indicated the IDT met to discuss ongoing behavioral concerns which included Resident 1's repeated episodes of attempting to get up unassisted and behaviors have persisted despite redirection efforts. The note indicated Resident 1's Responsible Party (RP) was present during the IDT meeting. During a review of the facility's Witness Fall Report, dated 9/26/2025, indicated Registered Nurse (RN) 1 stated on 9/26/2025 at approximately 3:15 p.m., while at the nurses' station, she heard Certified Nurse Assistant (CNA) 1 in the hallway telling Resident 1 to sit down. RN 1 then saw Resident 1 had fallen to the floor as CNA 1 approached her (Resident 1).During a continued review of the facility's Witness Fall Report, dated 9/26/2025, indicated CNA 1 stated on 9/26/2025, she was walking down the hallway when she saw Resident 1 stand up from her wheelchair. CNA 1 reported that she ran toward Resident 1 while shouting for her to stop but was unable to reach her in time. CNA 1 stated Resident 1 fell to the floor and landed on her right side.During a review of Resident 1's COC Evaluation, dated 9/26/2025, the COC indicated Resident 1 was sitting in a wheelchair in the hallway when she stood up unassisted from her wheelchair, took a step and fell to the floor and landed on her right side. The COC indicated Resident 1 was transferred to the GACH for further evaluation.During an interview on 11/19/2025, at 11 a.m., RP 1 stated on 9/25/2025, Resident 1 hit herself on the head with the TV mount during an attempt to get out of bed unassisted. RP 1 stated on 9/26/2025, she was notified that Resident 1 attempted to get out of her wheelchair unassisted resulting in a fall. RP 1 stated during her meeting with the IDT on 9/25/2025 she was informed by the facility that they would ensure Resident 1 was supervised to prevent further falls.During an interview on 11/20/2025, at 12:22 p.m., the Director of Rehabilitation (DOR) stated Resident 1 had poor safety awareness but was able to sit in a wheelchair with supervision. The DOR stated Resident 1 required verbal cues, redirection, and tactile cues to ensure she was safe while sitting in the wheelchair.During an interview on 11/20/2025, at 2:53 p.m., CNA 1 stated she was walking down the hallway when she saw Resident 1 trying to get up from her wheelchair. CNA 1 stated Resident 1 was approximately five to six feet in front of her when she saw Resident 1 trying to get up, she shouted at Resident 1 to stop and not to get up several times, but Resident 1 did not listen to her. CNA 1 stated she ran to Resident 1 but was unable to reach her in time and Resident 1 fell to the ground and landed on her right side. CNA 1 stated RN 1 was seated at the nurses' station and did not have access to Resident 1 when she fell. During an interview on 11/20/2025, at 3:16 p.m., RN 1 stated on 9/26/2025, she was seated at the nurses' station while Resident 1 was in a wheelchair approximately four feet away, on the opposite side of the desk and not within arm's reach. RN 1 stated she was not actively observing Resident 1 when she heard CNA 1 shouting. RN 1 stated from the corner of her eye, she saw Resident 1 fall to the floor. RN 1 stated she was unable to intervene in time to prevent the fall.During an interview on 11/21/2025, at 2 p.m., the Director of Nursing (DON) stated Resident 1's care plan required her to remain at the nurses' station for supervision due to previous attempts of attempting to get out of bed unassisted and Resident 1's poor safety awareness. The DON stated that staff needed to keep Resident 1 in their view to redirect her from trying to get out of her wheelchair. The DON stated methods to redirect Resident 1 to maintain safety would include speaking to her clearly and directly, using tactile cues and distraction. The DON stated this was the first time she was aware of Resident 1 attempting to get out of her wheelchair unassisted. The DON stated that despite CNA 1 shouting for Resident 1 to stop, neither CNA 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 11/21/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nor RN 1 were able to reach Resident 1 in time to prevent her from falling to the ground.During a review of the facility's Policy and Procedure (P&P) titled, Fall and Fall Risk Managing, dated 2001, the P&P indicated the staff with the input of the attending physician, will implement a resident centered -fall prevention care plan to reduce the specific risk factors of falls for each resident at risk or with the history of falls.During a review of the facility's P&P, titled, Safety and Supervision of Resident, dated 2001, the P&P indicated the following, our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents, the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific hazards or risks for individual residents, the care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive devices. The P&P indicated the importance of monitoring the effectiveness of interventions shall include ensuring that interventions are implemented correctly and consistently. Event ID: Facility ID: 555375 If continuation sheet Page 3 of 3