Health inspection·July 3, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of two facility-reported incidents. Facility-reported incident numbers: CA00898718 and CA00898566. Representing the Department: HFEN 39028. The inspection was limited to the specific facility-reported incidents investigated and does not represent the findings of a full inspection of the facility. No deficiencies were written for facility-reported incidents number CA00898566. One deficiency was written as a result of facility-reported incident number CA00898718. See Tag F689.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/14/2024 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 056711 Facility ID: CA940000029 If continuation sheet 1 of 8 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055995 (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH LONG BEACH POST ACUTE 260 E Market St Long Beach, CA 90805 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to ensure, residents, assessed at risk for falls, did not have a fall, for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 3) did not leave Resident 1 unsupervised when Resident 1 was sitting at the edge of the bed. 2. Ensure CNA 3 followed the facility's policy and procedure (P&P) titled "Answering the Call Light" which indicated to call another staff for help by using the call light for assistance. CNA 3 left Resident 1 sitting at the edge of her bed unattended and went to the resident's restroom to get some gloves. 3. Ensure staff followed Resident 1's care plan titled "Resident at risk for fall related to poor safety awareness, cognitive (ability to think, understand, learn, and remember) loss, and visual limitation which indicated staff will assist Resident 1 getting in and out of bed, and perform frequent visual checks. The deficient practices resulted in an unavoidable fall on 5/4/2024 and Resident 1 sustained a right inferior pubic ramus fracture (crack or break in the pelvis [basin-shaped complex of bones that connect the trunk and the legs]). Resident 1 was hospitalized at the General Acute Care hospital (GACH) for orthopedic ([ortho] field of medicine specialize in injuries of the muscles, bones, joints, ligaments, and tendons) evaluation and management from 5/4/2024 and discharged back to the facility on 5/6/2024. Findings: A review of Resident 1's Admission Record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 056711 Facility ID: CA940000029 If continuation sheet 2 of 8 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055995 (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH LONG BEACH POST ACUTE 260 E Market St Long Beach, CA 90805 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated Resident 1 was admitted to the facility on 3/21/2018 with diagnoses including hypertensive heart disease with heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), osteoporosis (condition in which bones become weak and brittle), dementia (loss of memory, language, problem-solving and other thinking abilities) and difficulty in walking. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and carescreening tool), dated 2/9/2024, indicated Resident 1's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 1 required maximal assistance (helper gets more than half the effort) from staff for upper body dressing, lower body dressing and personal hygiene and moderate assistance (helper does less than half the effort) on oral hygiene, toileting hygiene, toileting, and showering. The MDS indicated Resident 1 required moderate assistance walking 150 feet. The MDS indicated Resident 1 used walker for assistance in moving. The MDS indicated Resident 1 was incontinent (inability to control bladder and bowel functions) of urine and bowel. The MDS also indicated Resident 1 had a history of falls with injuries. A review of Resident 1's care plan titled "Resident at risk for fall related to poor safety awareness, cognitive loss, and visual limitation dated 1/24/2024 indicated Resident 1 will minimize episode of falls through the next review date of 5/17/2024. The Care Plan indicated interventions including fall mat (a rectangular floor pads with inner surface made of foam or other cushiony materials used to provide a softer place for the resident to land when falling especially if the resident falls from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 056711 Facility ID: CA940000029 If continuation sheet 3 of 8 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055995 (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH LONG BEACH POST ACUTE 260 E Market St Long Beach, CA 90805 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the bed) while resident in bed, provide extensive assistance to the resident with getting in and out of bed, and frequent visual check. A review of Resident 1's care plan titled "Resident at risk for ADL Self-care performance deficit related to impaired function and mobility, cognition, diagnosis of dementia, and depression (persistent feeling of sadness and loss of interest in activities)" dated 3/23/18, indicated staff will assist Resident 1 with activities of daily living ([ADLs] daily self-care activities) as needed. A review of Nursing Progress Note dated 5/4/24 timed at 11:15 a.m., indicated Resident 1 fell on 5/4/2024 at 11:06 a.m., due to Resident 1 not asking for assistance. The Nursing Progress Note indicated Resident 1 complained of a pain level of 10 out of 10, on a zero to ten pain rating scale (where 0 indicates no pain and 10 was worse possible pain) to the right side of her head, right arm, and right leg. The Nursing Progress Note indicated Resident 1 was observed with facial grimacing (distort face in an expression usually of pain) and holding the right side of her ribcage (bones in the chest). The Nursing Progress Note indicated 911 (a phone number used to contact emergency services) was called and the resident was transferred to the GACH on 5/4/2023 at 12:15 p.m. A review of Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) note dated 5/4/24 timed at 11:30 a.m., indicated on 5/4/24 at around 11:06 a.m., Resident 1 was observed on the floor by the foot of the bed towards the left side. The IDT note indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 056711 Facility ID: CA940000029 If continuation sheet 4 of 8 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055995 (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH LONG BEACH POST ACUTE 260 E Market St Long Beach, CA 90805 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1's roommate witnessed the fall and stated Resident 1 was sitting at the edge of the bed, reached to her walker with one hand and when Resident 1 grabbed the walker, she lost her balance and fell backwards. A review of Resident 1's GACH History and Physical indicated Resident 1's Computed Tomography ([CT] an imaging test used to detect internal injuries) of the chest, abdomen, and pelvis on 5/4/2024 at 7:27 p.m. indicated a right inferior pubic ramus fracture. A review of Resident 1's GACH report titled "Medicine for Discharge Summary under 48 hours", dated 5/6/2024, indicated Resident 1 was admitted for further orthopedic ([ortho] field of medicine specialize in injuries of the muscles, bones, joints, ligaments, and tendons) evaluation and management from 5/4/2024 and discharged back to the facility on 5/6/2024. The report indicated based on Resident 1's imaging results, the ortho did not recommend surgical intervention, the resident's pubic rami fracture will be treated conservatively. The report indicated recommendations including weightbearing (amount of weight a resident put on an injured body part) as tolerated to right lower extremity, elevate and ice right hip as needed, always use assistive devices with ambulation, Lovenox (medication to prevent blood clots), for 2 weeks after discharge, and follow-up with ortho as outpatient in 3 to 4 weeks, for repeat imaging and to discuss advancing weight bearing. During an interview on 5/16/24 at 12: 20 p.m., Resident 1 stated one day, she slipped and fell in her room. The resident could not remember the date and time. During an interview on 5/16/2024 at 1:15 p.m., with the Director of Nursing (DON) in Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 056711 Facility ID: CA940000029 If continuation sheet 5 of 8 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055995 (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH LONG BEACH POST ACUTE 260 E Market St Long Beach, CA 90805 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1's room, the DON stated Resident 1 had history of multiple falls. The DON stated Resident 1 had a fall in 1/2024 (cannot remember the exact date). The DON stated prior to Resident 1's fall on 5/4/2024, Resident 1 used a rollator walker (a device used to walk with wheels and a seat) where she sat but was discontinued after the resident fell on 5/4/2024. The DON stated Resident 1 needed assistance form staff on getting up from a sitting position, and ambulating (walking). The DON stated CNA 3 should not have left Resident 1 sitting at the foot of the bed unattended. The DON stated Resident 1's fall was avoidable if CNA 3 did not leave Resident 1 unattended on 5/4/2024. During an interview on 5/16/24 at 2:20 p.m., with CNA 1, CNA 1 stated she was in another room when she heard a loud noise coming from Resident 1's room. CNA 1 stated when she entered Resident 1's room, Resident 1 was on the floor. CNA 1 stated Housekeeper 1 and CNA 3 got the resident up and took Resident 1 to the dining room. CNA 1 stated Resident 1 was sitting in the dining room when she started complaining of headache and the resident was observed with a big bump on the right side of her head. During an interview on 5/21/24 at 12:40 p.m., with CNA 3 stated on 5/4/24 at around 11 a.m., when she entered Resident 1's room, Resident 1 was sitting up at the foot of the bed. CNA 3 stated she asked Housekeeper 1 to watch and talk to Resident 1 while she went to the bathroom to grab a pair of gloves. CNA 3 stated when she left Resident 1, Resident 1 got up to walk with her rollator walker and fell. CNA 3 stated Resident 1 slipped, fell, and hit her head. CNA 3 stated she should not have left Resident 1 unattended while sitting at the foot of the bed and ready to get up. CNA 3 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 056711 Facility ID: CA940000029 If continuation sheet 6 of 8 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055995 (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH LONG BEACH POST ACUTE 260 E Market St Long Beach, CA 90805 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she should have asked another staff to get her a pair of gloves and not leave Resident 1. CNA 3 stated she should have assisted Resident 1 to a wheelchair to ensure her safety. CNA 3 stated Resident 1 fell on the left side of her bed and hit her head on the bedside table. CNA 3 stated she (CNA 1) came in after she heard a noise coming from Resident 1's room. CNA 3 stated Resident 1 complained of headache, LVN (unknown) was notified and 911 was called. CNA 3 stated an ambulance arrived and took Resident 1 to GACH on 5/4/2024 around 12 p.m. CNA 3 stated Resident 1's fall was avoidable if she did not leave her unattended. CNA 3 stated Resident 1 should have had a wheelchair instead of a rollator walker to prevent further falls. During an interview on 5/21/24 at 12:44 p.m., with Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) 1, OT 1 stated Resident 1 required a one-person assistance to get in and out of the bed and going to the bathroom. OT 1 stated CNA and licensed staff were instructed not to leave Resident 1 by herself as she was a high risk for fall. A review of facility's policy and procedures (P&P) titled "Falls Management" dated 5/26/2021, indicated residents will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. A review of facility's P&P titled "Answering the Call Light" revised on 9/2022, indicated "If assistance is needed when you (staff) enter the room, summon help by using the call signal." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 056711 Facility ID: CA940000029 If continuation sheet 7 of 8 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055995 (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTH LONG BEACH POST ACUTE 260 E Market St Long Beach, CA 90805 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 056711 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA940000029 (X5) COMPLETE DATE If continuation sheet 8 of 8