Health inspection·January 17, 2025

Code of Federal Regulations section 483.10(i) Safe Environment The resident has a right to a safe and homelike environment, including but not limited to receiving treatment and supports for daily living safely. California Health and Safety Code section 1569.282 A licensee that permits residents to possess firearms on the facility premises shall do all of the following: (c) Residents’ and licensees’ firearms, ammunition, or both shall be centrally stored in the facility and in the following manner: (1) Firearms shall be centrally stored unloaded, in a locked gun safe, that meets the regulatory standards established by the Department of Justice in Section 4100 of Title 11 of the California Code of Regulations. California Code of Regulations section 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. On 12/13/2024, the California Department of Public Health (CDPH) received a complaint indicating a gun was found in a resident’s belongings (Resident 1), who expired at the facility (non- gunshot related) on 11/24/2024. On 12/14/2024 at 8:30 a.m., CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1.) Ensure Resident 1 did not have a gun in his possession and that the facility implemented its policy and procedure (P&P) titled, “Firearms (a rifle, pistol, or other portable gun) and other Weapons (any object used in fighting or war, such as a gun, bomb, knife),” which stated the facility prohibited (forbid) any resident from possessing firearms or other weapons designed for bodily harm while in or on the facility’s premises. 2.) Ensure signage was posted to communicate the facility’s policy prohibiting the possession of firearms or other weapons while in or on the facility’s premises. As a result, this placed the safety of residents, staff, and visitors in jeopardy and at risk for injuries and death from accidental or intentional shooting from the gun. Resident 1 was a 58-year-old male, admitted to the facility on 10/5/2024, with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), opioid dependence (a chronic disease that occurs when someone regularly uses opioids [strong pain killers] and develops a strong drive to continue using them, even when it causes harm), Schizophrenia (a mental illness that is characterized by disturbances in thought) and suicidal ideations (thinking about or planning suicide.) A review of Resident 1’s physician’s order dated 10/6/2024, indicated Resident 1 may go Out on Pass (OOP) for four (4) hours. A review of Resident 1’s History and Physical (H&P) dated 10/7/2024, indicated Resident 1 had the mental capacity to understand and make medical decisions. A review of Resident 1’s Psychology Diagnostic Assessment dated 10/8/2024, indicated Resident 1 alert, cooperative, responsive to questions and was feeling okay with normal adjustment at the facility. The Assessment indicated Resident 1 did not report suicidal ideation and appeared to have stable mood with no acute distress. A review of Resident 1’s Minimum Data Set ([MDS] a resident assessment tool), dated 10/11/2024, indicated Resident 1 had the ability to make himself understood and the ability to understand others. The MDS indicated Resident 1 required supervision or touching assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). A review of Resident 1’s OOP sheet, indicated on 10/6/2024 at 11:00 a.m. Resident 1 went OOP to a store and returned at 2:45 p.m. The OOP sheet indicated on 10/7/2024 at 12:30 p.m., Resident 1 went to the store and returned at 3:05 p.m. The OOP sheet indicated on 10/15/2024 at 2:00 p.m., Resident 1 went to the store and returned at 5:00 p.m. The OOP sheet indicated on 11/12/2024 at 12:37 p.m., Resident 1 went to the store and returned to the facility at 2:00 p.m. The OOP sheet for 10/6/2024, 10/7/2024, 10/15/2024 and 11/12/2024 did not indicate Resident 1 was checked for items brought back to the facility upon return. A review of Resident 1’s progress notes dated 10/6/2024, 10/7/2024, 10/15/2024, and 11/12/2024, did not indicate Resident 1 was assessed upon return to the facility from OOP. A review of Resident 1’s progress notes dated 11/24/2024, at 2:58 p.m., indicated on 11/24/2024 at 7:57 a.m., a facility staff (unnamed) discovered a gun with the resident’s belongings during postmortem care (care of a deceased body). A review of Resident 1’s Quality Assurance Action Plan (QA) dated 11/24/2024, indicated during postmortem care and the collection of Resident 1’s belongings, a firearm was discovered. The QA indicated the Long Beach Police Department (LBPD) was notified, arrived at the facility at 12:08 p.m., and confiscated (removed) the firearm. During an interview on 12/14/2024 at 12:15 p.m., with the Director of Nursing (DON), the DON stated the charge nurse called and notified her (the DON) that Resident 1, who died on 11/24/2024, had a gun inside his bag, that was placed on the floor beside the nightstand. The DON stated residents were not allowed to have any guns or knives in their belongings, for everyone’s safety. The DON stated the possession of a gun caused a safety issue and had the potential to cause harm to everybody in the facility. The DON stated it was the facility’s responsibility to provide a safe environment for residents’ safety. During an observation on 12/15/2024 at 9:00 a.m. at the facility’s entrance, the facility hallways, activity room and residents’ rooms, had no signs posted indicating the facility prohibit the possession of firearms, knives, or weapons in the facility. During an interview on 12/15/2024 at 1:34 p.m., with the Medical Doctor (MD), the MD stated a resident with a gun in the facility placed the other residents’ safety in danger. During an interview on 12/19/2024 at 12:07 p.m. with Receptionist (Recep) 2, Recep 2 stated when Resident 1 went OOP, she (Recep 2) made sure the nurses were notified Resident 1 was out of the facility. Recep 2 stated she had not checked the facility’s policy about OOP and was not sure what the OOP policy was. Recep 2 stated, it was important to assess residents when they left and returned to the facility to know what items they brought back with them. During an interview on 12/19/2024 at 1:17 p.m., Licensed Vocational Nurse (LVN) 3 stated, “we do not let newly admitted residents go OOP within 3 days of admission”. LVN 3 stated residents with psychiatric issues would need to go out with supervision unless the primary doctor and psychiatrist ordered for the resident to go OOP independently. LVN 3 stated when Resident 1 came back from OOP, Resident 1 should have been assessed physically by Licensed Nurses and the assessment documented in the progress notes. During a concurrent interview and record review on 12/19/2024 at 1:55 p.m. with Registered Nurse (RN) 1, RN 1 stated newly admitted residents were monitored for 72 hours. RN 1 stated Resident 1 should have been assessed when he returned from OOP, especially the items Resident 1 brought back to the facility. A review of the facility’s P&P titled, “Safety and Supervision of Residents,” dated 2001, indicated resident safety and supervision to prevent accidents are facility wide priorities. The P&P indicated safety risk and environmental hazard should be identified on an ongoing basis. The P&P indicated employee should be trained how to identify and report potential accident hazards. The P&P indicated the care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision. A review of the facility’s P&P titled, Firearms and Other Weapons, dated 2001, indicated the facility prohibited any employee, resident, visitor, vendor, or any individual from possessing firearms or other weapons designed for bodily harm while on the facility’s premises. The P&P indicated, signage should be posted throughout the building relative to the facility’s policies governing the possession of firearms or other weapons while in or on the facility’s premises. The facility failed to: 1.) Ensure Resident 1 did not have a gun in his possession and that the facility implemented its policy and procedure (P&P) titled, “Firearms (a rifle, pistol, or other portable gun) and other Weapons (any object used in fighting or war, such as a gun, bomb, knife),” which stated the facility prohibited (forbid) any resident from possessing firearms or other weapons designed for bodily harm while in or on the facility’s premises. 2.) Ensure signage was posted to communicate the facility’s policy prohibiting the possession of firearms or other weapons while in or on the facility’s premises. As a result, this placed the safety of residents, staff, and visitors in jeopardy and at risk for injuries and death from accidental or intentional shooting from the gun. This violation had a direct or immediate relationship to the health, safety, or security of all residents, staff, and visitors in the facility.