Health inspection·May 1, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AMENDED 9/9/2024 The following reflects the findings of the California Department of Public Health during the investigation of one complaint and one facility-reported incident. Complaint numbers: CA00888387, CA00887224, and CA00888014. Facility-reported incident number: CA00887991. Representing the Department: HFEN 45425. The inspection was limited to the specific complaints and facility-reported incident investigated and does not represent the findings of a full inspection of the facility. No deficiencies were identified for complaint and facility-reported incident numbers CA00887224, CA00888014, and CA00887991. One deficiency was identified for complaint number CA00888387. See tag F867.

F867 SS=F QAPI/QAA Improvement Activities CFR(s): 483.75(c)(d)(e)(g)(2)(i)(ii)

F867 04/15/2024 §483.75(c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: 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: 3JPO11 Facility ID: CA940000089 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: _______________ 056007 (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC CARE NURSING CENTER 3355 Pacific Pl Long Beach, CA 90806 (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 §483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement. §483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators. §483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation. §483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events. §483.75(d) Program systematic analysis and systemic action. §483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. §483.75(d)(2) The facility will develop and implement policies addressing: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JPO11 Facility ID: CA940000089 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: _______________ 056007 (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC CARE NURSING CENTER 3355 Pacific Pl Long Beach, CA 90806 (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 (i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. §483.75(e) Program activities. §483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problemprone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care. §483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility. §483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JPO11 Facility ID: CA940000089 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: _______________ 056007 (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC CARE NURSING CENTER 3355 Pacific Pl Long Beach, CA 90806 (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 section. §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility ' s Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families) committee failed to: 1. Have a policy and procedure (P&P) in place regarding the management and care of residents with the diagnoses of seizures, convulsions, and epilepsy, including how to identify those residents at risk and implement seizure precautions. 2. Identify, assess, and implement seizure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JPO11 Facility ID: CA940000089 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: _______________ 056007 (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC CARE NURSING CENTER 3355 Pacific Pl Long Beach, CA 90806 (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 precautions for 24 residents, in the facility with diagnoses of seizures, convulsions, epilepsy, and on anti-seizure medications These deficient practices placed 24 residents with diagnoses of seizure, convulsions, or epilepsy at risk for falls and injuries during seizure activities. Findings: a. During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on 2/10/2024 with diagnoses including epilepsy and systemic lupus erythematosus (SLE- when the body ' s immune system attacks the tissue and organs). During a review of Resident 1 ' s History and Physical (H&P) dated 2/13/2024, the H&P indicated Resident 1 had a fluctuating capacity to understand and make decisions. During a review of Resident 2 ' s Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on 12/19/2022 with the diagnosis of unspecified convulsions. During a review of Residents 2 ' s MDS dated 12/22/2023, the MDS indicated Resident 2 was in a persistent vegetative state (awake with no signs of awareness). The MDS indicated Resident 2 was completely dependent on staff for activities of daily living (ADLs- eating, drinking, transferring, dressing and toileting). The MDS indicated Resident 2 had a diagnosis of a seizure disorder or epilepsy. During a review of Resident 2 ' s physician orders dated 11/30/2023, the order indicated give 10 millimeters ([ml] unit of measurement) Levetiracetam (medication used to treat seizures) through a gastrostomy tube (tube FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JPO11 Facility ID: CA940000089 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: _______________ 056007 (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC CARE NURSING CENTER 3355 Pacific Pl Long Beach, CA 90806 (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 inserted through the wall of the abdomen into the stomach for food and medication administration) every eight hours for seizure disorder. During a review of Resident 2 ' s care plan titled "High risk for trauma/injuries related to diagnosis of seizure disorder," dated 4/26/2023, the care plan goal indicated Resident 2 will not have a traumatic injury, if possible, within next 3 months. The care plan interventions included keeping environment free of safety hazards. c. During a review of Resident 3 ' s Admission Record, the Admission Record indicated Resident 3 was admitted to the facility on 4/12/2023 with the diagnosis of other seizures. During a review of Residents 3 ' s MDS dated 12/22/2023, the MDS indicated Resident 3 ' s cognition (ability to learn, remember, understand, and make decision) was severely impaired. The MDS indicated Resident 2 was completely dependent on staff for ADLs. The MDS indicated Resident 3 had a diagnosis of a seizure disorder or epilepsy. During a review of Resident 3 ' s physician order dated 8/14/2023, the order indicated Levetiracetam 10 millimeters every 12 hours through gastrostomy tube for seizure disorder. During an interview on 3/16/2024 at 9:36 a.m., with LVN 3, LVN 3 stated residents at risk for seizures were identified on admission by their diagnosis and medications ordered for seizures. LVN 3 stated seizure precautions should be implemented when residents were admitted with diagnoses of seizure, convulsion and epilepsy and were on anti-seizure medications to prevent falls and injuries seizures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JPO11 Facility ID: CA940000089 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: _______________ 056007 (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC CARE NURSING CENTER 3355 Pacific Pl Long Beach, CA 90806 (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 an interview on 3/16/2024 at 10:04 a.m., with RNS 2, RNS 2 stated seizure precautions should be implemented upon admission, if a resident was identified at risk for seizure. RNS 2 stated during meetings and huddles (short daily meetings) staff were notified of residents at risk for seizures. RNS 2 stated she was unsure if the facility had a method to identify residents at risk for seizures such as a wrist band. RNS 2 stated any resident on seizure medications should be on seizure precautions because the medications could limit seizures, but not prevent them. During an interview on 3/16/2024 at 11:45 a.m. with the DON, the DON stated upon admission a resident was identified as at risk for seizure based on the resident ' s seizure medications. The DON stated since Resident 1 was not prescribed any seizure medication, Resident 1 ' s seizure history was unknown. The DON stated if the seizure diagnosis was not identified and seizure precautions were not implemented, residents could suffer an injury during a seizure. The DON stated the MDSN and RNS should have followed up to ensure care plan interventions were implemented for seizure precautions for Resident 1. The DON stated the facility did not have a policy on seizure management and precaution. The DON stated the QAPI committee was focused on falls and pressure wounds. The DON stated the committee was collecting data regarding the number of falls, during what shift they occur on and what staff are working. The DON stated the ADM and DSD were focused on abuse training. The DON stated seizure management and prevention were not really looked at because the committee was more focused on priority items including the use of bed rails. During a review of the facility ' s policy and procedure (P&P) titled "Quality Assurance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JPO11 Facility ID: CA940000089 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: _______________ 056007 (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC CARE NURSING CENTER 3355 Pacific Pl Long Beach, CA 90806 (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 Performance Improvement Plan & Committee (QAPI)" dated 9/2017, indicated the QAPI committee identifies and addresses specific care and quality issues and implements an action plan to resolve these issues. The P&P indicate the QAPI plan identifies and prioritizes problems and opportunities for improvement. Cross reference to F689 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JPO11 Facility ID: CA940000089 If continuation sheet 8 of 8