Health inspection·June 30, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure Certified Nurse Assistant (CNA)1 placed the foot pedals (also known as foot rests- designed to provide postural support and stability as well as distribute weight bearing during sitting or transporting) before transporting Resident 1 to the dining room for lunch via wheelchair.This failure resulted in Resident 1 wearing non-skid shocks (also known as non-slip or gripper socks, are socks with textured or rubberized soles designed to increase traction and prevent slipping on smooth surfaces) being thrust out from wheelchair due to friction (the resistance that one surface or object encounters when moving over another) while CNA 1 was pushing the wheelchair. Resident 1 sustained small cut on mid forehead and a superficial abrasion (a superficial wound caused by the scraping or rubbing away of the skin's outer layer) on the right knee.During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last re-admission was on 7/16/2020 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), cerebrovascular disease (CVA-stroke, loss of blood flow to a part of the brain) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knees.During a review of Resident 1's Minimum Data Set ([MDS]-a resident assessment tool), dated 4/24/2025, the MDS indicated Resident 1 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, hygiene, dressing, and maximal assistance (Helper does more than half the effort.) from one staff for bed mobility, eating. The MDS indicated, Resident 1's cognitive (the mental processes of knowing, learning, and understanding) skills for daily decision making were moderately impaired (poor decision making and required supervision).During a concurrent observation and interview on 6/30/2025, at 11:55 a.m., with CNA 2 in the dining room, Resident 1 was sitting on a high back wheelchair (a wheelchair that provide enhanced support, stability, and comfort, particularly for individuals with limited upper body strength or specific medical conditions) with foot pedals attached. Resident 1 was wearing yellow non-skid socks. Resident 1 had a small scar on mid forehead. Resident 1 had right hand contracture (a condition where the fingers become bent or flexed towards the palm, making it difficult to straighten them) and was unable to lift his feet. CNA 2 stated, the foot pedals should be used while transporting via wheelchair because Resident 1's feet would be dragged, especially with non-skid socks on.During a concurrent interview and record review on 6/30/2025, at 2:31 p.m., with Licensed Vocational Nurse Unit Manager (LVN UM)1, Resident 1's Fall Risk Assessment (FRA), dated 6/18/2025 was reviewed. The FRA indicated, Resident 1's FRA score was 9. LVN UM 1 stated, FRA score above 10 indicated a risk for potential fall and the score below indicated no fall risk. LVN UM 1 stated, Resident 1 was at low risk for fall due to limited mobility. Residents Affected - Few Page 1 of 2 555823 555823 06/30/2025 Intercommunity Care Center 2626 Grand Avenue Long Beach, CA 90815

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN UM 1 stated, he believed that Resident 1 required foot pedals all time when Resident 1 was sitting on wheelchair and during the transportation for safety.During an interview on 6/30/2025, at 2:52 p.m., with CNA 1, CNA 1 stated, Resident 1 required foot pedals on while transported via wheelchair. CNA 1 stated, CNAs were not assigned to specific residents. CNA 1 stated, she was passing by the dining room and saw Resident 1 was brought in front of the dining room entrance in a wheelchair. CNA 1 stated, she pushed Resident 1's wheelchair to place him near the dining table and she felt the resistance. CNA 1 stated, Resident 1 was big and tall guy, so she pushed little harder to overcome the resistance. CNA 1 stated, she realized Resident 1 was leaning toward his right side and fell out of the wheelchair. CNA 1 stated, she tried to assist Resident 1 not to hit hard on the floor. CNA 1 stated, she noticed Resident 1's foot pedals were not on, and Resident 1 was wearing non-skid socks. CNA 1 stated, the friction between his feet with non-skid socks and the force from the pushing wheelchair probably caused the fall. CNA 1 stated, she was not the one who placed Resident 1 in wheelchair. CNA 1 stated, she should have checked the placement of foot pedal before transporting him to prevent the fall accident.During a phone interview on 6/30/2025, at 4:44 p.m., with Director of Rehabilitation (DOR), DOR stated, not all residents required foot pedals and footrest. DOR stated, if the resident had limited mobility and did not have good control over lower extremities, especially their feet, he recommended using foot pedals and footrest at all times to prevent accidents such as falls. DOR stated, Resident 1 had poor control of lower extremities, and foot pedals were required during the transporting via wheelchair for safety.During a concurrent interview and record review on 6/30/2025, at 5:05 p.m., with Administrator (ADM), Resident 1's Investigation for all incidents, dated 6/18/2025 was reviewed. The Investigation for all incidents indicated, Interdisciplinary Team (IDT-a group of healthcare professionals from different disciplines who collaborate to provide comprehensive care to residents) findings indicated staff was pushing Resident 1 in wheelchair without foot pedals and Resident 1 fell forward out of wheelchair. The Investigation for all incidents indicated, IDT recommended was always placing foot pedals on wheelchair. ADM stated, the staff should have ensured the placement of foot pedals even though they were not assigned to Resident 1 for safety to prevent falls or accidents. ADM stated, these falls caused injuries such as fracture led to pain and limited mobility. During a review of Resident 1's Care Plan (CP), dated 6/18/2025, the CP Concerns and Problems indicated, Resident 1 had a fall incident on 6/18/2025. The CP Resident Goals indicated, minimize potential fall within the next review period. The CP Approach Plan (interventions) indicated, place foot pedals when up in wheelchair and ensure the resident wears appropriate footwear.During a review of Resident 1's Physical Therapist Evaluation & Plan Treatment, dated 1/16/2025, the Physical Therapist Evaluation & Plan Treatment indicated, Resident 1 was at risk for fall. The Physical Therapist Evaluation & Plan Treatment indicated, Resident 1 had poor sitting balance and both lower extremities had impaired (weakened, diminished, damaged, or functioning poorly) range of motion (ROM -the extent of movement that a joint can perform.During a review of the facility Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, revised 12/2007, the P&P indicated, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.During a review of the facility's Policy and Procedure (P&P) titled, Accidents and Incidents - Investigating and Reporting, revised 12/2007, the P&P indicated, Policy Interpretation and Implementation : 7. Incident/ Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. 555823 Page 2 of 2