Other·November 27, 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 of a Complaint investigation during an Abbreviated Standard Survey. Complaint number: CA006652677 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 37393 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for CA00652677

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/12/2019 §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's staff failed to maintain the 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: 06LD11 Facility ID: CA940000046 If continuation sheet 1 of 5 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 10/29/2019 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 whereabouts at all times for one of three sampled residents (Resident 1), who had a high risk for elopement (to flee or to run away secretly). Resident 1, who was confused and at risk for elopement and falls, left the facility unsupervised and was later found by a local postal worker on the street, and picked up in the personal vehicle of a facility staff member. This deficient practice of the facility not providing Resident 1 adequate supervision, resulted in the resident leaving the facility in a wheelchair for an unknown amount of time. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 4/20/18, and readmitted on 2/26/19. Resident 1's diagnoses included Alzheimer's disease (a progressive degenerative disease of the brain that leads to dementia and memory loss), muscle weakness, and history of falls resulting in fracture (broken bone). A review of Resident 1's care plan, initiated on 9/3/18, identified a problem of, "Observed going towards exit doors and has stated she wants to go home". The goal indicated Resident 1 would not wander outside the facility for three months. The staff interventions included to alert all staff to maintain whereabouts of resident at all times, wander guard (alarm device applied to the arm or leg to alert staff when resident is at an exit/entrance door) bracelet at all times (check every shift), anticipate physical needs, and distract and redirect resident away from facility door repeatedly. A review of the licensed nurse's progress note, dated 4/22/19 and timed at 1:55 p.m., indicated Resident 1 was noted asking staff for directions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06LD11 Facility ID: CA940000046 If continuation sheet 2 of 5 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 10/29/2019 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 to exit the facility because she wanted to go home. The noted indicated Resident 1 was noted making her way towards the exit door, and was redirected to nurse's station to call her family member. The note indicated Resident 1's physician made aware and received an order to apply a wander guard to alert staff of the resident's attempt to elope from the facility. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 6/10/19, indicated Resident 1 had memory problems, impaired decision-making, and was able to make needs known and able to understand others. According to the MDS, the resident was assessed requiring extensive assistance with bed mobility, transferring, locomotion on and off the unit, dressing and with personal hygiene. According to the MDS, section P200, Resident 1 required a wander/elopement alarm daily. A review of the licensed nurse's progress note, dated 8/17/19, and timed at 6:00 p.m., indicated Resident 1 was found outside by Certified Nurse Assistant 1 (CNA 1) in her wheelchair, wandering in the parking lot of the facility. The note indicated Resident 1 was brought back inside and assessed, the resident's physician was called and received an order for one on one (1:1) sitter for 72 hours. On 8/30/19 at 5:39 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated all facility staff members were looking for Resident 1, who had eloped from the facility, and she was found by a staff member (CNA 1) on the street not far from the facility. On 8/30/19 at 5:58 a.m., during an interview, CNA 1 stated all the facility staff were looking for Resident 1, and they were unable to find her anywhere in the facility. CNA 1 stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06LD11 Facility ID: CA940000046 If continuation sheet 3 of 5 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 10/29/2019 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 drove her car around the area, and saw Resident 1 sitting in her wheel chair, talking with a postal worker. CNA 1 stated she pulled her personal vehicle over, and identified herself to the postal worker. CNA 1 stated her facility name badge was used to identify herself to the postal worker, and Resident 1 was placed in her personal vehicle along with the wheelchair to go back to the facility. CNA 1 stated the Director of Nursing (DON) was made aware Resident 1 was missing and returned to the facility. On 9/4/19 at 10:09 a.m., during an interview, the DON stated he was notified by a Registered Nurse (RN) supervisor that Resident 1 was missing and a search of the neighborhood was initiated. The DON stated Resident 1 left out of the facility in her wheelchair through a rear door that has an elopement alarm, and Resident 1 used the ramp with her wheelchair to elope. The DON stated the incident was not reported to the Department of Public Health (DPH) because Resident 1 was gone from the facility for a short time, and she did not receive any injuries. The DON stated after speaking with the Administrator (ADM) and the consultant of the facility, they agreed the incident was not a reportable event. The DON stated Resident 1 was on monitoring for elopement and the facility staff monitor the rear door. On 9/6/19 at 10:58 a.m., during a telephone interview, the ADM stated he was informed of Resident 1's elopement. The ADM stated he spoke with the facility's consultant who deemed the elopement of Resident 1 a non-reportable incident. The ADM acknowledged DPH was not notified of Resident 1's elopement from the facility. A review of the facility's policy titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06LD11 Facility ID: CA940000046 If continuation sheet 4 of 5 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 10/29/2019 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 "Wandering, Unsafe resident," indicated, the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06LD11 Facility ID: CA940000046 If continuation sheet 5 of 5