Other·September 11, 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 California Department of Public Health during the investigation of two Complaint during an Abbreviated survey. Complaint Numbers: CA00693565 and CA00693733 Representing the Department of Public Health: Health Facility Evaluator Nurse ID: 16282 The Inspection was limited to the specific complaint investigations and does not represent the findings of a full inspection of the facility. There was a deficiency issued for Complaint Numbers CA00695565 and CA00693733.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 08/28/2020 §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 observation, interview and record reviews, the facility failed to prevent elopement (act or instance of leaving a safe area or safe premises done by a person with a mental disorder) and adequate supervision for one of 3 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: V19811 Facility ID: CA940000090 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: _______________ 056313 (X3) DATE SURVEY COMPLETED 08/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC VILLA, INC. 3501 Cedar Ave Long Beach, CA 90807 (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 sampled residents (Resident 1). The facility did not provide a wander guard and frequent monitoring as indicated in the Elopement Risk Assessment recommendations. Resident 1 was had a history of elopement behaviors left the facility without being notice due to the facility failing to provide a wander guard (ensuring the alarm is activated and staff respond to the alarm when a patient or resident attempts to leave a safe area). This deficient practice resulted in resident 1 eloping from the facility and being found on the streets that placed the resident at a high risk for harm. The emergency medical services (EMS) transported the resident to the general acute care hospital (GACH) 2 hours later. Findings A review of the Face Sheet indicated Resident 1 was originally admitted to the facility on 1/29/2020 and readmitted on 6/2/2020. The diagnoses included unspecified schizophrenia ((a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning). The History and Physical, dated 2/10/2020, indicated Resident 1 had a fluctuating capacity to understand and make decisions. A review of Resident 1's Initial Wandering Assessment, dated 2/7/2020 indicated the resident was at risk for wandering. The assessment was to be completed on admission to assist in determining risks for wondering. There were 8 questions documented and if two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V19811 Facility ID: CA940000090 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: _______________ 056313 (X3) DATE SURVEY COMPLETED 08/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC VILLA, INC. 3501 Cedar Ave Long Beach, CA 90807 (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 or more responses to the questions were answered "yes" the resident was placed on "Wander Risk." Resident 1 had six "yes" responses to the assessment. A review of Resident 1's Elopement Risk Assessment, dated 2/8/2020 indicated the types of interventions to be taken included frequent monitoring, identification bracelet and picture on the medication administration record (MAR). Resident 1 should be offered recreational activities, music and exercise. In the area Summary/ Conclusion/ Recommendations indicated Resident 1 wandered around, going from room to room and a wander guard was placed. A review of the Nursing Care Plan, dated 2/9/2020, indicated Resident 1has episodes of trying to leave the facility unassisted/without a companion. The approach plan included to provide of constant monitoring of resident's whereabouts, maintain identification in chart using personal photos and to apply a wander guard alarm to alert staff when resident attempts to leave the facility unassisted/ without companion. The plan was re- evaluated May 20, 2020. A review of the Minimum Data Set (MDS), an assessment and care screening tool, dated 5/18/2020, indicated the resident had the ability to understand and make himself understood. The resident was moderately impaired in cognitive skills with a brief interview for mental status (BIMS) score of 9. (00-15). The MDS indicated Resident 1 had no behavior of wandering. The resident required limited assistance with bed mobility, transfer, walking and locomotion of unit. The MDS indicated Resident 1 had no functional limitation in range of motion (full movement of joints), The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V19811 Facility ID: CA940000090 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: _______________ 056313 (X3) DATE SURVEY COMPLETED 08/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC VILLA, INC. 3501 Cedar Ave Long Beach, CA 90807 (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 required no mobility devices (walker or wheelchair etc.). A review of the Initial Wandering Assessment and Elopement Risk Assessment sheet dated 6/2/2020 was incomplete. The risk of wandering was not determined. The interventions continued with frequent monitoring, identification bracelet and pictures in the MAR/chart. There was no care plan indicated and the summary /conclusion/ recommendations were left blank. A review of a Physician Orders dated 6/2/2020 at 7 p.m., indicated Resident 1 may go out on temporary leave of absence with companion. A review of the Resident 1's Nurses Progress Notes indicated the following on 6/21/2020: At 3:15 p.m., the resident was able to make his needs know with periods of confusion. At 3:30 pm, resident 1 was in the patio having a smoking break. At 5 p.m. dinner was served to Resident 1. At 7 p.m. Resident 1 was observed lying in bed asleep. At 8 p.m., Resident 1 was noted on the smoking patio At 8:30 p.m., Resident 1 was not in his room, the resident's bathroom, the smoking patio and the hallway was searched, unable to locate the resident's whereabouts. The staff searched the entire building and the parking lot. At 9:30 pm, staff contacted police department. At 10:30 pm, the physician and son were called, and left a message to voice mail for the responsible party (RP/son) several times. A review of the Resident 1's Nurses Progress Notes indicated on 6/22/2020 at 7:45 a.m., the RP asked staff if the cameras had been checked to see what door Resident 1 left out of. Staff informed the RP that they did not have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V19811 Facility ID: CA940000090 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: _______________ 056313 (X3) DATE SURVEY COMPLETED 08/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC VILLA, INC. 3501 Cedar Ave Long Beach, CA 90807 (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 cameras at the back door or inside the building. A review of the Resident 1's Nurses Progress Notes indicated on 6/22/2020 at 8:45 a.m., the CNA states Resident 1 was in his room 36 (at the rear of the building near the exit to the parking lot) where he was being watched by a staff due to Resident 1 leaving the building four (4) times. The staff informed the RP that all residents are being watched especially the ones that was risk for elopement. A review of the Resident 1's Nurses Progress Notes indicated on 6/22/2020 at 10:00 a.m., the nurse placed a call to a general acute care hospital (GACH) to inquire if the resident was admitted. The registered nurse (RN) at the GACH informed the facility's nurse that Resident 1 was admitted 6/21/2020 at 11 pm. According to the RN at the GACH the son was informed that Resident 1 was admitted. A review of the GACH's Emergency Department Note, the physician indicated on 6/21/2020 at 11:15 p.m., The Chief Complaint indicated Resident 1 was brought in by ambulance from the streets. The patient was confused, he stated he fell (unknown injury) then stated he got hit by a truck. The History of Present Illness indicated, per emergency medical services (EMS) run sheet, "the patient was found seated on curb, complained of "hernia pain", reported a fall and felt pain in his elbow." Resident 1 was admitted to the GACH in guarded condition. On 6/22/2020 the Complainant/ Responsible party notified the GACH that Resident 1 was resident at the Skilled nursing facility and had eloped from the facility on 6/21/2020. Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V19811 Facility ID: CA940000090 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: _______________ 056313 (X3) DATE SURVEY COMPLETED 08/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC VILLA, INC. 3501 Cedar Ave Long Beach, CA 90807 (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 had significant dementia did not know where he was but was able to follow simple commands. A review of the facility's Elopement policy not dated indicated the facility shall promptly report any resident who tries to leave premises to the Charge Nurse or Director of Nursing. If the resident is not located notifications include the department of Public Health. If the employee discovers that a resident is missing from the facility, he/she shall start searching for the resident and if not found, notify the Administrator, DON, the resident's legal representative, attending physician, law enforcement and emergency management agencies. Also provide search teams with resident identification information. There was not supportive documentation provided by the facility that emergency management agencies were contacted and search teams with resident identification information was conducted. On 6/23/2020, at 10 a.m., during interview the RP stated Resident 1 was a wanderer upon admission on 1/29/2020, because he wanted to go home. The staff mentioned a wander guard being placed on the resident but did not place a wander guard and the resident had no identification band on when found 6/21/2020. RP stated he found Resident 1 at the GACH when he stopped by to check if the resident had been brought there. RP further stated staff were to watch Resident 1. There was to be a relief staff watching the resident, when the staff watching the resident, went to lunch. On 6/23/2020 at 3:55 p.m., during an interview Licensed Nurse (LN1) stated on the night of 6/21/2020, Resident 1 was just wandering around the facility. There was no care plan for Resident 1's wandering behavior or elopement. At 4:10 p.m., the Director of Nursing (DON) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V19811 Facility ID: CA940000090 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: _______________ 056313 (X3) DATE SURVEY COMPLETED 08/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC VILLA, INC. 3501 Cedar Ave Long Beach, CA 90807 (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 stated she did not complete an investigation of Resident 1's elopement due to the resident was found in the hospital within 24 hours. On 6/23/2020 at 4:20 p.m., during an interview LN 2 stated on 6/21/2020, Resident 1 was a wandering most of the time, the resident told LN 2 and CNA 1 that he was going home that day. CNA 1 was supposed to monitor Resident 1 with frequent checks every hour. CNA 1 sat next to the resident's room (36) and no one saw the resident leave the building. LN 2 stated everyone was very busy and the resident could easily open the slide door and the gate outside was always open. LN 2 further stated CNA 2 should monitor Resident 1 when CNA 1 took a break. On 6/23/2020 at 4:40 p.m., during an interview CNA 2 stated when CNA 1 went to break, he assisted with monitoring Resident 1. A week ago, Resident 1 said he wanted to go home and was looking for the keys to his car. CNA 2 stated Resident 1 wandered from his room to the smoking patio and back to the nurse's station. When he (CNA 2) returned from his break he did not know where Resident 1 was located. CNA 2 further stated there was an alarm on the back door to the parking area, but staff turns it off when going out. On 6/23/2020 at 5:15 p.m., during an interview and observation accompanied by CNA 2 and Resident 2 who was alert and oriented to name, place and time. Resident 2 stated he was Resident 1's roommate and he saw Resident 1 leave out the rear door and go over the fence at the back of the facility. Resident 2 stated he saw Resident 1 go to the bus stop by the train (over the fence at the rear of the facility). The facility's rear door adjacent to the kitchen and dining room was open and there were only two to three low beeps when the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V19811 Facility ID: CA940000090 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: _______________ 056313 (X3) DATE SURVEY COMPLETED 08/21/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC VILLA, INC. 3501 Cedar Ave Long Beach, CA 90807 (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 door was opened. At 5:20 p.m., CNA 2 stated on 6/21/2020 Resident 1 was wandering all over like crazy, staff was unable to do anything with the resident. Resident 1 continuously went out the door saying he wanted to go home. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V19811 Facility ID: CA940000090 If continuation sheet 8 of 8