Other·January 11, 2019

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 Department of Public Health during the investigation of a Facility Reported Incident (FRI) investigation during an Abbreviated Standard Survey. Facility Reported Incident number: CA00601151 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 39028 The inspection was limited to the specific FRI investigation and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for Facility Reported Incident CA00601151

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 12/22/2018 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); 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: 6YIW11 Facility ID: CA940000046 If continuation sheet 1 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy by not ensuring a resident's representative was notified prior to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 2 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 discontinuation of a one to one ([1:1] one on one supervision of a resident) sitter for safety for one of three sampled residents (Resident 1). (Cross referenced to F689). This deficient practice resulted in Resident 1 having an unwitnessed fall, after being left without a sitter for safety, and being transferred to the general acute care hospital (GACH) for further care and evaluation. Findings: Resident 1's Admission Record (Face Sheet) indicated the resident admitted to the facility on 8/14/18. Resident 1's diagnoses included traumatic subdural hemorrhage (bleeding in the space between the outer layer and middle layers of the covering of the brain) with loss of consciousness of unspecified duration, traumatic subarachnoid hemorrhage with loss of consciousness, difficulty walking, cognitive communication deficit (inability to make decisions), and a history of repeated falls. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 8/23/18, indicated the resident's cognition (ability to reason and make decisions) was impaired. According to the MDS, Resident 1 required extensive to total assistance with all activities of daily living (ADLs), which included a two-person physical assist for bed mobility, toilet use, and a oneperson assist with eating and personal hygiene. A review of an Admission Nursing Assessment, dated 8/14/18, indicated Resident 1 had vision impairment and required a one-person assist with ambulation, transfer, and partial weight bearing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 3 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 A review of a Physician's Order, upon admission, dated 8/14/18, indicated a 1:1 sitter for safety and fall precaution. A review of a Care Plan, dated 8/15/18 and titled, "Potential for Falls or Injury," manifested by staff dependence for transfer and locomotion, cognitive deficit, and poor safety awareness. The goal was to minimize falls or injury every shift. The staff's interventions included to provide constant monitoring and notify the physician of any unusual observation and provide a 1:1 sitter to prevent injury from falling. A review of Resident 1's History and Physical, dated 8/15/18, indicated the resident did not have the capacity to understand and make decisions A review of a Physical Therapy Daily Treatment Note, dated 8/16/18, indicated Resident 1 required maximal verbal and tactile (touch) cues. The note indicated Resident 1 was retropulsive (loss of balanced) with all functional mobility A review of a Nursing Progress note, dated 8/22/18, indicated Resident 1 was alert and oriented with no sitter today, at fall risk. A review of a Nursing Progress note, dated 8/23/18 and timed at 2:40 a.m., indicated Resident 1 was awake and attempted to get out of bed several times. Another Nursing Progress note, dated 8/23/18 and timed at 5:15 a.m., indicated at approximately 3:55 a.m. 1 was found on the floor near the closet at the foot of the bed in a sitting position and complained of head and right hip pain. According to the note, there was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 4 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 a 4.5 centimeter (cm) by 5 cm edematous (an accumulation of an excessive amount of watery fluid) lump observed above the right eye. Vital signs were indicated as Temperature (T) -98.8, pulse (P) -67, Respirations (R) -18, Blood Pressure (BP) -169/76, SPO2-95, and Blood sugar (BS) -161. According to the note, Resident 1 was also placed on 1:1 due to falls at home and high risk for recurrent fall. The note indicated Resident 1 was confused and forgetful with episodes of clarity. A review of a document titled, "SBAR" (Situation, Background, Acknowledgement, Recommendation), dated 8/23/18, indicated Resident 1 was admitted to the facility for traumatic subdural hemorrhage from past history of fall at home. A review of a Case Management Progress note, dated 8/21/18, indicated Resident 1's family was not in agreement and aware of the plans. The note indicated the Case Manager discussed a meeting will be held again tomorrow with resident's son. A review of Physician's Order, dated 8/22/18, indicated Resident 1's Last Cover Day ([LCD] the length of day the resident's health insurance can pay for services received) was 8/25/18 and to discharge the resident home, discontinue sitter. A review of Nurses progress Note, dated 8/22/18, indicated LCD 8/25/18 for discharge home with home PT, discontinue sitter, patient son aware; but no specification of person,time, and date patient son was made aware. During a telephone interview, on 9/6/18 at 11:30 a.m., Resident 1's family member (FM 1) stated that he did not receive prior notification regarding the discontinuation Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 5 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 sitter by the facility. FM 1 stated, "My mom could not walk without assistance and that was why she had a sitter everyday. She had a bruise on her forehead and broke her hip. She was confused in the facility that was why she had a sitter. She had a sitter in the hospital prior to admission into facility and continued to have a sitter while admitted into facility. The only time the Nurse Practitioner took the sitter away was when she fell and sustained a hip fracture with bruises on forehead, and the condition is worst." During a face -to-face interview, on 9/10/18 at 8:50 a.m., FM 1 stated, "On 8/22/18 around 4:30 p.m., when I arrived at facility my mother was in the room with no sitter. The roommate's son was in the room visiting with his mother and he said that my mom has been very agitated trying to get out of bed so he had to go get some of the nurses because she was trying to get out of the bed. When I asked the Case Manger about my Mom's sitter she said "it is not me; I do not get into that; That was the nurse Practitioner that took your Mom off the sitter". FM 1 stated no one called to inform him about the plan of discontinuing the sitter, and it took less than 24 hours of discontinuing the sitter for Resident 1 to fall and sustain another fracture with bruises on the forehead and the resident's condition had gotten worse than before. FM 1 further stated, "I asked the Administrator, the primary physician, Case Manager, and Nurse Practitioner (NP) and none of them could tell me why they took the sitter away." FM 1 stated Resident 1's physician stated that since he was the resident's physician, he would take the responsibility of discontinuing the sitter. During a telephone interview, on 9/27/18 at 9:30 a.m., the NP stated, " Usually when we make decisions, we do not always have to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 6 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 involve the resident's representative, but with what happened, I think there is a need to involve the resident's representative during care decisions." During an interview, on 9/27/18 at 10:02 a.m., the Case Manager stated, "Resident 1's son had came to me while I was in the office and asked who made the order to remove his mom's sitter and I said to him that I do not know who made the order. I do not make orders, it is the responsibility of the facility to keep residents safe." During an interview, on 10/18/18 at 2:59 p.m., Registered Nurse 1 (RN 1) stated, "I was in the facility on 8/22/18, around 1-2 p.m. I had an order from the Nurse Practitioner regarding Resident 1's LCD, and the fact that they are going to discontinue the sitter. It is our protocol that by the time they gave the order, the family has been notified by our facility social worker, case managers, and the NP. I can not remember the day, time, and means I used to notify son with discontinuing of Resident 1's sitter. I am not 100% sure." A review of the facility's undated policy and procedures titled, "Policy Interpretation and Implementation," indicated the resident and/or representative will be informed of the plan to discontinue sitter as ordered by the physician. Upon discontinuation of sitter, resident will be placed on close observation by the facility staff for at least 72 hours to ensure that the discontinuation of a sitter is appropriate.

F689 Free of Accident Hazards/Supervision/Devices F689 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 12/22/2018 Facility ID: CA940000046 If continuation sheet 7 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=G CFR(s): 483.25(d)(1)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §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: Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure adequate supervision was provided to prevent falls with injuries for one of three sampled residents (Resident 1). Resident 1, who was confused and had a high risk for falls, had a recent change in condition, after a one to one ([1:1] one on one supervision of a resident) sitter was discontinued, became agitated and was constantly attempting to get up out of bed unsupervised, fell and sustained injuries. (Cross referenced F580) This failure of not providing close supervision resulted in Resident 1 falling sustaining blunt head trauma with a right eye hematoma (collection of clotted blood in the tissues) and a right femoral neck (hip bone) fracture (broken bone) requiring a transfer to a general acute care hospital (GACH) and undergoing a surgical repair of the right hip. Findings: A review of Resident 1's Admission Record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 8 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 (Face Sheet) indicated the resident was admitted to the facility on 8/14/18 with diagnoses that included traumatic subdural and subarachnoid hemorrhage (bleeding in the space between the outer layer and middle layers of the covering of the brain) with loss of consciousness of an unspecified duration, difficulty in walking, and history of repeated falls. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 8/23/18, indicated the resident's cognition (ability to reason and make decisions) was impaired. According to the MDS, Resident 1 required extensive to total assistance with all activities of daily living (ADLs), which included a two-person physical assist for bed mobility, toilet use, and a oneperson assist with eating and personal hygiene. A review of a Physician's Order, upon admission, dated 8/14/18, indicated a 1:1 sitter for safety and fall precaution. A review of an Admission Nursing Assessment, dated 8/14/18, indicated Resident 1 had vision impairment and required a one-person assist with ambulation, transfer, and partial weight bearing. A review of a Care Plan, dated 8/15/18 and titled, "Potential for Falls or Injury," manifested by staff dependence for transfer and locomotion, cognitive deficit, and poor safety awareness. The goal was to minimize falls or injury every shift. The staff's interventions included to provide constant monitoring and notify the physician of any unusual observation and provide a 1:1 sitter to prevent injury from falling. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 9 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 A review of Resident 1's History and Physical, dated 8/15/18, indicated the resident did not have the capacity to understand and make decisions A review of a Physical Therapy Daily Treatment Note, dated 8/16/18, indicated Resident 1 required maximal verbal and tactile cues. The note indicated Resident 1 was retropulsive (loss of balance) with all functional mobility. A review of a Nurses Progress note, dated 8/22/18, indicated Resident 1's Last Cover Day ([LCD] the length of day the resident's health insurance can pay for services received) was 8/25/18. Resident 1 was to be discharged home with home physical therapy (PT) and to discontinue the sitter. A review of a Nursing Progress note, dated 8/22/18, indicated Resident 1 was alert and oriented without a sitter today, at fall risk. A review of a Nursing Progress note, dated 8/23/18 and timed at 2:40 a.m., indicated Resident 1 was awake and attempting to get out of bed several times. Another Nursing Progress note, dated 8/23/18 and timed at 5:15 a.m., indicated at approximately 3:55 a.m. 1 was found on the floor near the closet at the foot of the bed in a sitting position and complained of head and right hip pain. According to the note, there was a 4.5 centimeter (cm) by 5 cm edematous (an accumulation of an excessive amount of watery fluid) lump observed above the right eye. Vital signs were indicated as Temperature (T) -98.8, pulse (P) -67, Respirations (R) -18, Blood Pressure (BP) -169/76, SPO2-95, and Blood sugar (BS) -161. A review of a Physician's Order, dated 8/22/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 10 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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's LCD was 8/25/18, and to discontinue the sitter. A review of a Nurses Progress note, dated 8/22/18, indicated Resident 1 was disoriented to place, time, situation, easily distracted, frequently incontinent (unable to control bowel and bladder function), and forgetful. A review of a Nurses Progress note, dated 8/23/18, indicated a large hematoma measuring at 4.5 cm by 5 cm above Resident 1's right eye. Resident 1 complained of right hip pain of 8 out of 10 on a pain measuring scale (8/10) with movement and tender to touch. A review of a SBAR ([Situation, Background, Acknowledgement, and Recommendation] internal communication tool) Communication Form and Progress Note, dated 8/23/18, indicated Resident 1 made attempts to get out of bed during the night shift. The assigned Certified Nurse Assistant (CNA), who had 15 other residents to care for, left Resident 1's room to speak with an LVN, at which time a noise was heard and Resident 1 was found sitting on the floor against the closest. Swelling was noted on Resident 1's right forehead which measured 4.5 cm by 5 cm, and Resident 1 had complaints of right hip pain. A review of the GACH Admission Record, dated 8/23/18, indicated Resident 1's X-ray results was positive for the displaced right hip femoral neck fracture. Resident 1 was admitted for a hip hemiarthroplasty (a surgical procedure that replaces one half of the hip joint). The GACH record indicated Resident 1 was recently discharged from the GACH a week prior for rehabilitation status-post ground level fall with traumatic subarachnoid hemorrhage and subdural hematoma (pool of blood between the brain and the outermost covering). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 11 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 During a telephone interview, on 9/6/18 at 11:30 a.m., Resident 1's family member (FM 1) stated that he did not receive any prior notification regarding discontinuation of the 1:1 sitter. FM 1 stated, "My mom could not walk without assistance that was why she had a sitter every day. She had a bruise on her forehead and broke her hip. She was confused in the facility that was why she had a sitter. She had a sitter why in the hospital prior to admission into facility and continued to have a sitter while admitted into facility. The only time the Nurse Practitioner took the sitter away that was when she fell and sustained a hip fracture with bruises on forehead, and the condition is worst. On 9/10/18 at 8:50 a.m., during a face-to-face meeting, FM 1 stated "Resident 1 was transferred to the facility from the GACH on 8/14/18. FM 1 stated on 8/22/18 at around 4:30 p.m., during a visit to the facility, Resident 1 was in the room without a sitter. FM 1 stated Resident 1's roommate FM, who was also visiting, stated Resident 1 had been very agitated trying to get out of bed, so he went to get some of the nurses because the resident was trying to get out of bed. During an interview on 9/6/18 at 10:12 a.m., Certified Nurse Assistant 1 (CNA 1) stated, "I was doing all I could to take care of the resident (Resident 1). I stepped out for about 10 minutes and I heard a loud noise and ran back into the room and found the resident (Resident 1) sitting on the floor. CNA 1 stated it was her first night of taking care of Resident 1. CNA 1 stated she heard the resident did have a sitter, but the sitter was discontinued. CNA 1 stated she had 15 other residents that night. CNA 1 stated Resident 1 was supposed to be a one-to-one, but she was not at the time incident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 12 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 happened. CNA1 stated the Charge Nurse had discussed with her that Resident 1 was supposed to be a one-to-one, but had no sitter, so we have to do our best to take care of the resident. CNA 1 stated she stepped out to ask the Charge Nurse a couple of questions but did not ask for someone for relief. CNA 1 stated in the future in order to prevent this kind of incident, the facility needed to provide a one-toone sitter the resident. CNA 1 stated Resident 1 sustained a big bump on the forehead with pain at the time of the incident. During an interview, on 9/6/18 at 12:22 p.m., CNA 2 stated, "We were monitoring Resident 1, usually she had sitters. I was watching the resident with another CNA, when we went out to do our runs we heard a loud noise and we ran into the resident's room and found the resident in a sitting position with a bump on her forehead." CNA 2 stated they called the Registered Nurse supervisor (RN) who brought ice to apply to the bump. CNA 2 stated Resident 1 was a 1:1 care on assignment, but the facility could not provide the resident with one. CNA 2 stated if there was a bed alarm that would have prevented the fall. On 9/6/18 at 1:01 p.m., during an interview, the Director of Nursing (DON) stated, "After 2 p.m., on 8/22/18, Resident 1 did not have a sitter anymore and was taken to the activity room. The DON stated Resident 1 had history of multiple falls prior to admission to the facility. The DON stated, "With the resident being confused, I would say it was not okay to take the resident off 1:1 monitoring." The DON stated that the two CNAs assigned to care for Resident 1 during the night shift had other residents during the night and were alternating care in between. On 9/27/18 at 8:52 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 13 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 Nurse Practitioner (NP) stated, "When Resident 1's behavior changed on the afternoon of 8/22/18 by getting agitated and trying to get out of the bed the nursing staff should have called me or the physician to reorder a sitter for resident and this fall would have been prevented." The NP stated, "I rely on the report of the nurses and the documentation of the (PT) to make decisions." During an interview, on 9/27/18 at 10:02 a.m., the Case Manager (CM) stated, "Safety of the resident is the facility's responsibility". CM stated FM 1 came to my office and asked who decided to remove the sitter from Resident 1. The CM stated she told FM 1 did not know who made the decision, I reiterated it was the responsibility of the facility to keep residents safe. During an interview on 9/27/18 at 2:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated, "On the day of incident (8/23/18), I was in the nursing station when I heard a loud noise and we all ran to Resident 1's room and found the resident sitting on the floor with a bump on the forehead. There was no staff in the room when the resident fell." LVN 1 stated the 3-11 p.m. staff endorsed that Resident 1 was trying to get out of bed and they just said to keep an eye on the resident. LVN 1 stated if Resident 1 had a sitter the whole time she was in the facility this would not have happened. During an interview, on 10/18/18 at 2:59 p.m., Registered Nurse 1 (RN 1) stated "Around 3 p.m., on 8/22/18, Resident 1 started to become agitated and was trying to get out of the chair and bed. RN 1 stated she had the resident with her at the nursing station. RN 1 stated at approximately 4:30 p.m. on 8/22/18, the CM was leaving and RN 1 asked if there could be a sitter for Resident 1 because she could not be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 14 of 15 PRINTED: 05/14/2026 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: _______________ 056164 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 (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 sitter for the resident and work at the same time. RN 1 stated CM told her to observe the resident overnight and see how the resident does without a sitter. A review of the facility's undated policy and procedures titled, "Policy Interpretation and Implementation," indicated the nursing staff may serve as a sitter, when approved by the Director of Nursing Services. The resident and/or representative will be informed of the plan to discontinue sitter as ordered by the physician. Upon discontinuation of sitter, resident will be placed on close observation by the facility staff for at least 72 hours to ensure that the discontinuation of a sitter is appropriate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YIW11 Facility ID: CA940000046 If continuation sheet 15 of 15