Other·January 16, 2020

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) and Complaint investigations during an Abbreviated Standard Survey. Facility Reported Incident number: CA00652603 Complaint number: CA00652332 Complaint number: CA00654310 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 37393 The inspection was limited to the specific FRI and Complaint investigations and does not represent the findings of a full inspection of the facility. One deficiency was issued for CA00652332, CA00652603, and CA00654310

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 12/27/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 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: BLVD11 Facility ID: CA940000046 If continuation sheet 1 of 8 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 12/17/2019 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 §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its abuse policy by ensuring one of three sampled residents (Resident 1) were free from physical abuse by a facility staff member (Certified Nurse Assistant 1 [CNA 1]) during care, and report the incident to the facility's abuse coordinator. CNA 3 witnessed CNA 1 forcibly holding both hands over Resident 1's mouth, during care to muffle (to wrap or cover something in order to suppress sound) Resident 1's cries of distress. The incident was not documented or reported. This deficient practice resulted in Resident 1 being physically abused by CNA 1. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 8/3/19. Resident 1's diagnoses included muscle weakness, dysphagia (difficulty swallowing), aphasia (loss of ability to understand or express speech, caused by brain damage), altered mental status (a disruption in how the brain works and may cause changes in behavior), and vascular dementia (a condition characterized by a decline in memory, language, problem-solving and thinking skills that affect a person's memory caused by an impaired supply of blood to the brain). A review of Resident 1's admission Minimum Data Set (MDS), a resident assessment and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BLVD11 Facility ID: CA940000046 If continuation sheet 2 of 8 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 12/17/2019 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 care screening tool, dated 8/15/19, indicated Resident 1 had cognitive (thought process) problems, impaired decision-making, and was somewhat able to make needs known and somewhat able to understand others. According to the MDS, Resident 1 required extensive assistance with bed mobility, and was totally dependent on staff for transferring, locomotion on and off the unit, and with personal hygiene. A review of Resident 1's care plan, initiated on 8/5/19, identified a problem with altered thought process and compromised memory recall ability with impaired decision making ability related to dementia as manifested by confusion, disorientation, and unawareness of time, place and was unable to recognize staff names, faces and significant others. The goal indicated Resident 1's activities of daily living ([ADLs] every day activities such as dressing, grooming, bathing, and eating) would need to be anticipated. The staff interventions included cheerful dialogue with Resident 1 while performing ADLs, use resident's name when talking or during care, pleasant interaction which reassures resident when confused, explain all procedures, verbal reminders which assist resident to orientation, and approach resident warmly and kindly. A review of Resident 1's care plan, initiated on 8/22/19, identified a problem with attempting to strike staff. The goal indicated that the resident would have no further episodes of striking staff members during the stay at the facility. The staff interventions included keeping Resident 1's environment peaceful with minimal stimulants, frequently instruct resident in a friendly tone on acceptable behavior per protocol and do not force resident to perform tasks per physician order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BLVD11 Facility ID: CA940000046 If continuation sheet 3 of 8 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 12/17/2019 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 A review of a police report, dated 8/29/19 and timed at 11:36 a.m., indicated the police received a call about an incident that occurred on 8/26/19, and the suspect was an employee (CNA 1) and the victim was identified as Resident 1. The police report indicated another employee (CNA 3) witnessed the suspect put his hand over the victim's mouth because he was screaming. The police report indicated on 8/26/19, between the hours of 6:30 a.m. and 7 a.m., CNA 1 responded to Resident 1's room to assist CNA 2 with a patient (Resident 1). CNA 1 stated he wanted to assist CNA 2 because Resident 1 had a history of being combative and uncooperative when the staff attempted to assist him. The police report indicated CNA 1 stated Resident 1 was screaming and cursing at him and CNA 2. CNA 1 stated he grabbed Resident 1's arms and crossed them in an "X" motion across his chest. According to the police report, CNA 1 stated he gently crossed his arms for safety and for CNA 2's safety due to Resident 1 being combative. CNA 1 stated Resident 1 was attempting to punch him and CNA 2 as they were trying to change his attire (clothing). CNA 1 stated Resident 1 had previously punched him in the face in the past, therefore he held his arms down. According to the police report CNA 2 stated she did not see anything. On 8/30/19 at 3:14 a.m., during an interview, Registered Nurse (RN 1) stated she was told by CNA 3 on 8/26/19 that CNA 1 was seen covering the mouth of Resident 1. RN 1 stated that Resident 1 was confused and was very combative, and went to check the resident and saw CNAs 1 and 2 cleaning the resident. RN 1 stated she asked CNA 1 if he was covering Resident 1's mouth. RN 1 stated that CNA 1 stated he only held down the resident's hands so that the resident would stop hitting him. RN 1 stated she looked at the resident and did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BLVD11 Facility ID: CA940000046 If continuation sheet 4 of 8 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 12/17/2019 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 see any redness or bruising on Resident 1's mouth, and did not document the incident, or report the abuse allegation to the Director of Nursing (DON) or the Administrator (ADM), who was the abuse coordinator, because the resident was combative and she did not think it was a problem that needed to be reported. RN 1 acknowledged that she received abuse training, and was a mandated reporter, but that she assumed the Designated Staff Developer (DSD) would report the abuse allegation because he was told about the incident by another staff member. On 8/30/19 at 4:13 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 8/26/19 she was sitting at the nursing station when CNA 3 approached the station and told her and the RN supervisor (RN 1) he saw CNA 1 putting his hands over Resident 1's mouth. LVN 1 stated she went with RN 1 to check on Resident 1 and saw CNA 1 holding the resident down and CNA 2 cleaning him. LVN 1 stated Resident 1 always screamed during care so she did not think it was a problem. LVN 1 stated that she notified the DSD that morning about the abuse allegation regarding Resident 1 and CNA 1, but she did not document anything in the resident's chart or notify the DON or the ADM. On 8/30/19 at 6:48 a.m., during an interview, the DON stated he was notified about the abuse allegations concerning Resident 1 and CNA 1 on 8/29/19 after the Ombudsman ([OMB] an official appointed to investigate individuals' complaints against skilled nursing homes) visited the facility. The DON stated his staff did not report the abuse allegations to him, and it was their responsibility to report all abuse allegations to him. The DON stated Resident 1 was physically assessed and did not have any bruises or any other injuries. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BLVD11 Facility ID: CA940000046 If continuation sheet 5 of 8 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 12/17/2019 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 DON stated Resident 1's family member and the police were contacted about the abuse allegations, and CNA 1 was suspended pending the conclusion of the facility's investigation. On 8/30/19 at 7:58 a.m., during an interview, the DSD stated when he arrived to the facility for his shift on 8/26/19, he was approached by RN 1 and was informed Resident 1's abuse allegations. The DSD stated he asked RN 1 if she completed the necessary reports for the incident and she replied "yes." The DSD stated he reminded RN 1 to investigate the incident and interview all staff involved and she reassured him that she would. The DSD stated RN 1 had the abuse training many times, and because she was the RN supervisor she was aware that it was her responsibility as a mandated reporter. On 9/4/19 at 10:51 p.m., during an interview, CNA 3 stated he heard yelling on 8/26/19 in the hallway that suddenly became muffled. CNA 3 stated the other nurses nearby (RN 1 and LVN 1) heard the same yelling and screaming in a room close to the nursing station, but that he was the only staff member to respond. CNA 3 stated he entered Resident 1's room and upon entering, Resident 1's curtain was observed partially closed. CNA 3 stated he opened the curtain and observed CNA 1 on Resident 1's bed with both his hands over Resident 1's mouth pushing him down onto the pillow, telling the resident to "shut up!" in the presence of CNA 2. CNA 3 stated Resident 1 was still yelling, while CNA 1 was on top of him in the bed, and he asked CNA 1 what he was doing. CNA 3 stated at that time CNA 1 took his hands away from Resident 1's mouth, turned towards him with a shocked look on his face, but did not say anything. CNA 3 stated his stomach dropped and he was appalled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BLVD11 Facility ID: CA940000046 If continuation sheet 6 of 8 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 12/17/2019 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 (overcome with horror), disturbed and shaking as he rushed to the nursing station to notify RN 1 and LVN 1 at the nursing station of what he had just witnessed. CNA 3 stated RN 1 and LVN 1 did nothing and that he was unsure if Resident 1 had any injuries. CNA 3 stated he was a mandated reporter of abuse, and that there were several staff members aware of what happened. A review of the facility's policy titled, "Requesting, Refusing, and/or discontinuing care or treatment," indicated residents have the right to refuse or discontinue treatment prescribed by his or her healthcare practitioner, as well as care routines outlined on the resident's assessment and plan of care. The policy indicated a resident is not forced to accept any medical or treatment and may refuse or discontinue care or treatment at any time. A review of the facility's policy titled, "Abuse," revised 2/2019, indicated residents had the right to be free from abuse. The policy also indicated any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, isolation, financial abuse, or neglect or is told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, abandonment, isolation, financial abuse, or neglect, or reasonably suspects that abuse occurred shall report the known or suspected instance of abuse by telephone immediately (within 2 hours) or as soon as practicably possible, and by sending a completed "Report of suspected Adult/Elder abuse" within 5 working days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BLVD11 Facility ID: CA940000046 If continuation sheet 7 of 8 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 12/17/2019 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: BLVD11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA940000046 (X5) COMPLETE DATE If continuation sheet 8 of 8