Long Beach Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Service Director (SSD) documented services provided to the Emergency Contact (EC) 1 for one of five sampled residents (Resident 1) when EC 1 was assisted and updated in initiating a guardianship (an evaluation conducted to determine whether the individual needs assistance with decision making or with accomplishing activities of daily living) evaluation and completing documents necessary for guardianship. This failure has resulted in undetermined efforts of the facility in assisting EC 1 of the guardianship evaluation and had the potential for EC 1 to miss updates of the process requested.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent was obtained prior to administering amphetamine-dextroamphetamine ([Adderall] a psychotropic [any drug that affects a person's mental state, emotions, thoughts, or behavior] medication used to treat attention-deficit hyperactivity disorder [ADHD - a condition that makes it difficult to focus, stay organized and control restlessness) for one of four sampled residents (Resident 1). This failure resulted in Resident 1 receiving Adderall without documented informed consent, and without being informed of the medication's purpose, dose, risks, benefits and alternatives prior to administration. This failure had the potential for Resident 1 to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the grievance process was followed for one of four sampled residents (Resident 1). This failure resulted in Resident 1's grievance regarding food preferences being marked resolved without the identified problem being corrected, without the responsible department being notified, and without follow-up to verify resolution. This failure resulted in Resident 1 continuing to receive unwanted processed deli meats after the grievance was filed and had the potential to negatively impact Resident 1's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool) accurately reflected the active diagnoses of one of four sampled residents (Resident 1). This failure resulted in inaccurate diagnoses, incomplete nutritional assessments, and Care Plans that did not reflect Resident 1's gastric sleeve surgery (a surgery which permanently reduces stomach size and affects how much and what types of food the resident can tolerate), loose teeth, autism diagnosis (a developmental condition that affects how the resident understands information, communicates, interacts with others, and responds to sensory input), history of eating disorders, chewing problems, or food intolerances. These failures had the potential to negatively affect Resident 1's nutritional management, dietary tolerance, and individualized plan of care.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered Care Plan for Resident 1's autism (a developmental condition that affects how the resident understands information, communicates, interacts with others, and responds to sensory input) and bathing preferences/barriers for one of four sampled residents (Resident 1). This failure resulted in Resident 1's Care Plans not reflecting individualized interventions for cognitive, behavioral, hygiene, and physical care needs. This failure had the potential to negatively affect Resident 1's individualized care, hygiene, and overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff consistently identified, documented, and addressed the reasons for one of four sampled residents (Resident 1) repeated refusals of scheduled showers, and implement alternative approaches to provide adequate bathing and hygiene care. This failure resulted in Resident 1 not receiving showers for an extended period and had the potential to affect Resident 1's dignity and increase the risk for poor hygiene, skin breakdown, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Registered Dietician (RD) and Dietary Supervisor (DS) completed a comprehensive and accurate nutritional assessment for one of four sampled residents (Resident 1) to meet their individualized needs and dietary preferences. This failure resulted in Resident 1 receiving meals which did not align with her stated food preferences and nutritional needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff accurately documented when a resident (Resident 1) refused therapy and when Resident 1 was notified that her therapy services were discontinued for one of four sampled residents (Resident 1). This deficient practice resulted in an incomplete clinical record and had the potential to negatively affect Resident 1's continuity of care, care planning, skilled coverage decision-making, and the facility's ability to evaluate the appropriateness of therapy discontinuation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage of food was done under sanitary conditions in one of one kitchen by not labeling an opened food item with a date opened and prepared food items with date prepared. These deficient practices had the potential to cause food-borne illnesses (any illness resulting from eating contaminated/spoiled foods).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered care plan was developed and implemented for Risperdal [anti-psychotic medication (used to manage psychosis symptoms)] for one of four sampled residents (Resident 5). This deficient practice has the potential to result in unnecessary medication use, unmonitored side effects and decline in functional status.

Inspectors wroteBased on interview and record review, the nursing staff failed to revise a care plan for impaired communication for one of four sampled residents (Resident 30) who was deaf (condition where an individual has a significant or complete inability to speak) and non-verbal. This deficient practice had the potential for Resident 30's needs not to be met, due to her inability to express them. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hearing loss, non-verbal, and idiopathic peripheral autonomic neuropathy (IPAN: nerve damage affecting automatic functions (heart rate, blood pressure [amount of pressure that takes the heart to pump blood in the body], digestion). [...]

Inspectors wroteBased on interview and record review, the facility failed to document nursing assessment for the use of Continuous Positive Airway Pressure (CPAP, a machine that delivers air through a mask to keep the airway open during sleep and prevent breathing pauses) for one of three sampled residents (Resident 78). This deficient practice had the potential to result in inaccurate and incomplete resident records and delayed identification of respiratory support needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was newly admitted to the facility, from a psychiatric facility, was supervised, and monitored to prevent one out of three sampled residents (Resident 1) from eloping (leaving a secured institution without notice or permission) from the facility. Resident 1 was last seen in the facility on 10/4/2024 at approximately 8:30 p.m., on the facility ' s patio, smoking. Resident 1 was noted missing on 10/4/2024 at approximately 9 p.m., and found at his family ' s residence, 22 miles away on 10/5/2024 at 5:30 a.m. This deficient practice resulted in Resident 1 eloping from the facility on 10/4/2024 at approximately 9 p.m. and missing for over eight hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for 63 of 63 residents by not: 1. Labeling perishable food items (two open pasta bags) with open date. 2. Thawing diced beef according to facility policy. These deficient practices had the potential to cause food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure one of four sampled residents (Resident 116)'s narcotic (drug that affects mood or behavior) was documented in the narcotic record when it was administered on 9/11/2024 at 5 pm. b. Ensure one of three sampled resident's (Resident 53)'s home medications were documented when facility staff received it. These deficient practices had the potential to result in medication errors and drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of narcotics.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 61), who was diagnosed with post-traumatic stress disorder (PTSD - mental health condition that can develop after someone experiences a deeply distressing or disturbing event), received trauma informed care (a model that aims to provide effective mental health services by taking into account a person's past experiences with trauma). This deficient practice had the potential to result in resident 61's re-traumatization and can be detrimental for the resident's psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up and ensure one of eight sampled residents (Resident 7) received follow up dental care recommended by the dentist. This deficient practice had the potential to cause further decline in Resident 7's teeth and dental pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve a snack that was prepared as prescribed by the physician for one of two sampled residents (Resident 33). This deficient practice had the potential to cause the resident to choke on their food.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to document the visual monitoring for behaviors, every 15 minutes for one of one resident's (Resident 113)'s medical records. The deficient practice indicated an inaccurate account of care and services received by Resident 113, and the inability of the facility to recognize and act on trends of Resident 113's behaviors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a specialized tool due to its small size) that could cause food borne illness (food poisoning: illness due to consuming spoiled food) for residents in the facility by not: a. ensuring Strawberry ready care shakes (nutritional shake that gets delivered frozen) were dated, when placed in the refrigerator to thaw (once thawed, shelf life is less than 14 days) b. ensuring a salad and bowl of lettuce was labeled and dated in the refrigerator. c.ensuring a bowl of tuna salad, a container of cornflakes, and a tupperware of peaches were not expired. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to observe infection control measures by failing to ensure the dryer was running at the proper temperature. This deficient practice had the potential to place residents at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary social services for five of 15 sampled residents (Resident 38, Resident 40, Resident 42, Resident 47, Resident 53) by : a. not following up on an ophthalmology consultation recommendation to adjust new glasses for Resident 38. b. not following up on a dental recommendation for a full mouth x-ray and dentures for Resident 40. c. not ensuring Resident 42 was initially assessed and received individualized intervention to meet his mental and psychosocial needs. d. not following up on dental recommendations for a full mouth x-ray for Resident 47. e. not following up on an optometrist consultation for new reading glasses for Resident 53. This failure resulted in a delay of care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to provide routine dental service for three of 15 residents (Resident 40, Resident 47, and Resident 53). This failure resulted in Resident 40 and Resident 47 not receiving a recommended full mouth x-ray and Resident 53 not receiving new dentures.

Inspectors wroteBased on interview and record review the facility failed to provide privacy for one of 15 sampled residents (Resident 38) by discussing care and treatment of Resident 38 at the nurse's station in the presence of staff and other residents. This deficient practice had the potential to result in embarrassment and reveal private information for Resident 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a person-centered care plan for one of three sampled residents (Resident 41) for missing teeth. This deficient practice had the potential for Resident 41 to not be monitored for adverse outcomes of missing teeth such as choking due to trying to swallow unchewed food.

Inspectors wroteBased on interview and record review the facility failed to ensure two of 15 sampled residents (Resident 38 and Resident 53) optometrist (a healthcare professional who provides vision care) recommendations to arrange for Resident 38's new glasses, to be adjusted (to improve his sight) and to obtain new glasses for Resident 53 were followed. This failure resulted in a diminished quality of life for Resident 38 not being able to read fine print, and Resident 53 not having new glasses to maintain vision.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and reassess pain level on one of five sampled residents (Resident 9) in accordance with the standard practice of care. This deficient practice resulted in facility staff not reassessing Resident 9's pain level in a timely manner and placing Resident 9 at risk for unnecessary pain.