Colonial Care Center

F-F578, Advance Directives).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45382

Residents Affected - Some 45891

Based on observation, interview, and record review the facility failed to:

a. Notify one out of 10 sampled residents (Resident 188)'s physician (MD 1) and responsible party (FM 1) when Resident 188 had a change of condition related to significant weight loss of 7.6% (9lbs) in one month

on 1/3/2025, and 20.1% (24lbs) weight loss in 2 months on 1/31/2025.

b. report a change of condition (COC) for one of seven sampled residents (Resident 19) who was identified as being at high risk for contracture (loss of motion of a joint associated with stiffness and joint deformity) development and had limited range of motion (ROM, full movement potential of a joint) concerns by not Reporting Resident 19's refusal of Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services for range of motion (ROM, full movement potential of a joint) exercises to both legs in accordance with the facility's Policy and Procedure (P/P) titled, Change in a Resident's Condition or Status.

The deficient practice of Resident 188 had the potential to delay care, FM 1 would not be aware of the health status of Resident 188, and Resident 188 could be subject to further weight loss. Resident 188 was reweighed on 2/6/2025 and weighed 93.2 lbs. Resident 188 had severe weight loss of 25.8 lbs. or 21.6% in 60 days.

The deficient practice resulted of Resident 19 not receiving services and alternative interventions to improve ROM, prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), and improve overall mobility and physical functioning.

Cross reference:

F-F692)

Findings:

During an interview on [DATE REDACTED] at 7:42 p.m., the administrator (ADM) stated CPR and weight loss were not part of their current QAPI plan and the issues were not identified prior to the recertification survey [DATE REDACTED]-[DATE REDACTED]. The ADM stated these issues should have been caught via training and follow through, but

they were not.

During a review of the facility's policy and procedure (P/P) titled, Quality Assurance and Performance (QAPI) Program, revised ,d+[DATE REDACTED], indicated the facility implements and maintains an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) Program focused on the indicators of the outcomes of care and quality of life for our residents. The P/P indicated the objective of the QAPI program was to provide

a means to measure current and potential indicators for outcomes of care and quality of life and establish a system through which to monitor and evaluate corrective actions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45382 potential for actual harm 45891 Residents Affected - Some 46415

Based on observation, interview, and record review, the facility failed to observe infection control measures

on 5 of 37 sampled residents (Resident 19, 87,343,16) by failing to:

1. Ensure Restorative Nursing Aide 2 (RNA 2) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while providing range of motion (ROM, full movement potential of a joint) exercises to Resident 19 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms).

2. Ensure padded side rails (a padded side fitted to a bed for safety) were not wrapped with foam and paper tape for one of 10 sampled residents (Resident 87).

3. Ensure Resident 343 had an Enhanced Barrier Precaution (EBP: infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) signage posted for having a gastrostomy tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), foley catheter (a hollow tube inserted into the bladder to drain or collect urine), and a nephrostomy bag (urine drain from the kidney through an opening in

the skin on the back).

4. Ensure staff wore proper Personal Protective Equipment (PPE: equipment worn (gown, gloves, goggles) to help create a barrier between a healthcare worker and germs, bodily fluids) when touching the foley catheter of Resident 343 and staff wore PPE while doing care for Resident 16 who is on EBP.

The deficient practice of using a foam and paper tape prevented staff for proper cleaning and disinfection (the process of cleaning something, especially with a chemical, to destroy bacteria) of the padded side rails and could lead to the spread of infection to all other residents and staff.

The failure of RNA 2 not wearing isolation gown had the potential to transmit infectious microorganisms and increase the risk of infection among the residents and staff members.

The deficient practice of not following the proper usage of PPE while providing care put Residents, staff, visitors or vendors at risk for spread of infection.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 1. During a review of Resident 19's Admission Record, the Admission Record indicated the facility initially admitted Resident 19 on 9/10/2003 and readmitted Resident 19 on 5/20/2023 with diagnoses including Level of Harm - Minimal harm or C1-C4 quadriplegia (spinal cord injury in the neck region causing weakness or paralysis in both arms and potential for actual harm both legs), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain) and chronic obstructive pulmonary disease (lung disease that causes obstruction of airflow and can limit Residents Affected - Some normal breathing).

During a review of Resident 19's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/24/2024, for Resident 19 to be placed on EBP precautions.

During an observation on 2/4/2025 at 3:32 pm, in the resident's room, Resident 19 was lying in bed with both shoulders elevated on pillows to the side to shoulder height, both elbows bent, and the neck and upper body hunched forward. Resident 19 had a tracheostomy (a tube placed into a surgically created hole through the front of the neck and into the windpipe-trachea) tube. A sign that indicated Resident 19 was on EBP precautions was posted on the back wall behind Resident 19's bed. RNA 2 was standing next to Resident 19's bed wearing gloves on both hands and no isolation gown. RNA 2 stated she just completed passive range of motion (PROM, movement at a given joint with full assistance from another person) to Resident 19's left arm and was about to start ROM to Resident 19's right arm. RNA 2 picked up Resident 19's right arm and provided PROM to Resident 19's shoulder, elbow, wrist, and hand. Once RNA 2 completed exercises to Resident 19's right arm, RNA 2 removed both gloves, washed hands, and exited the room.

During an interview on 2/4/2025 at 3:45pm, RNA 2 stated she did not wear an isolation gown while providing PROM exercises to Resident 19 because she did not know Resident 19 was on EBP precautions. RNA 2 stated she did not see a sign indicating Resident 19 was on EBP precaution upon entrance to Resident 19's room and did not see the sign posted on the wall behind Resident 19's bed. RNA 2 stated she should have worn an isolation gown while providing PROM to Resident 19 because she provided direct care to Resident 19 who was on EBP precautions. RNA 2 stated it was important to follow infection control protocols to prevent the spread of infection.

During an interview on 2/6/2025 at 11:05 am, the Infection Preventionist Nurse (IPN) stated the purpose of EBP was to reduce the transmission of infections for residents with tracheostomies, gastronomy tubes (a tube placed directly into the stomach for long-term feeding), catheters (thin, flexible rube inserted into the bladder to drain urine), and open wounds. The IPN stated all staff must wear the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) which included an isolation gown and gloves during high contact activities such as providing PROM exercises to residents on EBP precautions to prevent the spread of infection.

During an interview on 2/7/2025 at 5:52 pm, the Director of Nursing (DON) stated it was important all staff followed the proper infection control protocols to prevent the spread of infection and cross contamination.

During a review of the facility's Policy and Procedure (P/P) titled, Enhanced [NAME] Precautions, revised 6/5/2024, the P/P indicated EBP precautions were used as an infection prevention and control intervention to reduce the spread of MRDO to residents. The P/P indicated EBP precautions required the use of gowns and gloves during high contact resident care activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. During a review of Resident 87's Admission Record, the Admission Record indicated Resident 87 was admitted to the facility on [DATE REDACTED] with diagnoses of epilepsy (a neurological disorder marked by sudden Level of Harm - Minimal harm or recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal potential for actual harm electrical activity in the brain) and encephalopathy (a change in how your brain functions).

Residents Affected - Some During a review of Resident 87's Minimum Data Set (MDS- a resident assessment tool) dated 11/6/2024, the MDS indicated Resident 87 was rarely or never understood.

During a review of Resident 87's Order Summary Report, an order was placed 12/27/2024 for low bed with bilateral upper padded half side rails up to decrease potential injury.

During an observation on 2/4/2025 at 9:05 a.m., Resident 87's bilateral upper side rails on his bed were wrapped in black foam and white paper tape.

During an interview on 2/7/2025 at 4 p.m., the infection prevention nurse (IPN) stated the facility used Diversey Oxivir 1 Disinfectant Cleaner on the padded side rails in the subacute unit (where Resident 87 resided) and Diversey Virex Plus- One Step Disinfectant Cleaner and Deodorizer for all other units in the facility. The IPN stated that the manufactures instructions on both products indicated they were to be used

on hard, nonporous (does not allow liquid or air to pass through it) surfaces. The IPN stated the foam and tape wrapped on the bedrails was not appropriate because they were porous and could cause the surface to not be cleaned properly and also break down the foam and tape.

During a review of the product label for Diversey Oxivir 1 Disinfectant Cleaner sku 100850916, the label indicated the product was an effective cleaner, disinfectant, and deodorizer for hard, nonporous inanimate (not alive) surfaces.

During a review of the product label for Diversey Virex Plus-One Step Disinfectant Cleaner and Deodorizer,

the label indicated the product worked as a disinfectant on hard, non-porous surfaces.

3. During a review of Resident 343's Admission Record, the Admission Record indicated Resident 343 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including g-tube, hydronephrosis (kidney swelling due to urine building up) with renal (kidney: organs that filter waste materials out of the blood) and ureteral calculous obstruction (blockage in the tube that carries urine from bladder caused by a kidney stone), and artificial opening of urinary tract status (conditions affecting the urinary system).

During a review of Resident 343's H&P dated 1/29/2025, the H&P indicated Resident 343 does not have the capacity to understand and make decisions.

During a review of Resident 343's MDS dated [DATE REDACTED], the MDS indicated Resident 343's cognitive skills were severely impaired. The MDS indicated Resident 343 is dependent on bathing, chair/bed-to-chair transfer, personal hygiene, toileting hygiene, oral hygiene, and required maximal assistance (helper supports more than half the effort required) for eating. The MDS indicated Resident 343 is impaired on both side of the upper and lower extremities.

During a review of the Order Summary (physician notes) dated 2/6/2025, the order summary indicated an active order for enhance barrier precautions related to (r/t) g-tube on 1/29/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation on 2/3/2025 at 10:51a.m. in Resident 343's room, Resident 343 had a g-tube, foley catheter, and a nephrostomy bag. Resident 343's room did not have any indication of EBP signage above Level of Harm - Minimal harm or the head of her bed or on the outside of the door or the hallway. potential for actual harm

During a concurrent observation and interview on 2/5/2025 at 11:27a.m. with Infection Preventionist Nurse Residents Affected - Some (IPN), IPN stated EBP was implemented in 2019 and is used for extra protection for residents who have g-tubes, open wounds, indwelling catheters as they are prone to getting infections, so it is imperative to protect the residents as much as possible. IPN stated Resident 343 has a g-tube, so the EBP sign would be placed on top of where the head of the bed is. IPN stated upon observation of Resident 343's room, indicated Resident 343 is supposed to have a EBP signage and does not have one. IPN stated hand hygiene is done as much as possible and is done before and after patient care. IPN stated if the staff is answering the call light and does not touch the resident, they do not have to do hand hygiene. IPN however stated it is common practice to do hand hygiene when leaving the residents room even if the staff did not touch the resident.

During a concurrent observation and interview on 2/5/2025 at 11:13a.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 was observed entering Resident 343's room with no PPE lifted the blanket that was covering the foley catheter, reached her hand inside the dignity bag (bag covering the foley catheter for privacy) to slightly expose the foley bag. CNA 3 stated she would wear a gown for precautions and if a resident has an infection, they are mandated to wear a gown. CNA 3 stated not wearing PPE can transmit

the infection to another resident. CNA 3 stated even with or without a precautionary sign on the wall, they are trained to wear PPE if they have a resident with a g-tube. CNA 3 stated she wears gloves for everything, however she indicated she did not wear gloves this time since she was requested to show the foley catheter for observation. CNA 3 was observed touching her mask with the same hand she touched the foley bag without performing hand hygiene. CNA 3 stated hand hygiene is performed before and after working with residents and before entering the resident's room.

During a review of Resident 16's Admission Record , the Admission record indicated Resident 16 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including gastrostomy, chronic obstructive pulmonary disease (COPD: a chronic lung disease causing difficulty in breathing), gastroesophageal reflux disease (GERD: stomach acid that flows back from the stomach into the tube that connects the mouth and stomach), and chronic kidney disease (moderate damage to the kidneys).

During a review of Resident 16's H&P dated 6/15/2024, the H&P indicated Resident 16 does not have the capacity to understand and make decisions.

During a review of Resident 16's MDS dated [DATE REDACTED], the MDS indicated Resident 16's cognitive skills were severely impaired. The MDS indicated Resident 16 is dependent on all aspects of activities of daily living (ADL: bathing, sit to lying, personal, toileting, oral hygiene, and eating. The MDS indicated Resident 16 is impaired on both the upper and lower extremities.

During a review of Resident 16's Order Summary dated 2/5/2025, the order summary indicated (Nepro: therapeutic nutrition designed for people who have reduced kidney function) at 50 cubic centimeter (cc: unit of volume that measures space occupied by solid or liquid) per hour (hr.) for 20 hours (hrs.) via pump to provide 1000CC/1800 kilocalories (kcals: unit measurement of energy used to describe calorie content of food) per day with an active date of 6/12/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a concurrent observation and interview on 2/5/2025 at 1:26p.m. with Registered Nurse 1 (RN 1), RN 1 was observed lifting up Resident 16's blanket to show the location of Resident 16's g-tube without wearing Level of Harm - Minimal harm or a gown when there was an EBP signage posted on top of Resident 16's head of the bed. RN 1 stated potential for actual harm Resident is on EBP precautions since she has a g-tube and will wear a gown and gloves as it can get on her clothes. RN 1 stated unless direct patient care is being provided, it is not necessary to wear a gown. Residents Affected - Some

During a review of the facility's P&P, titled Enhanced Barrier Precautions revised 6/5/2024, the P&P indicated enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply . gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering, transferring, provide hygiene, changing linens, device care or use (urinary catheter, feeding tube), and wound care. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless or MDRO colonization. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. Signs are posted outside of resident's room or head of the bed indicating the type of precautions and PPE required.

During a review of the facility's P&P, titled Handwashing/Hand Hygiene undated, the P&P indicated this facility considers hand hygiene that primary means to prevent the spread of healthcare-associated infections. Hand Hygiene is indicated after contact with blood, body fluids, or contaminated surfaces, after touching the resident's environment. Single-use disposable gloves should be used when anticipating contact with blood or body fluids and when in contact with a resident.

50144

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50144 potential for actual harm Based on interview and record review, the facility failed to implement the antibiotic stewardship program Residents Affected - Some policy when the antibiotic (a substance used to kill bacteria and to treat infections) did not meet Loeb's or McGeer's Criteria (criteria used to determine appropriate use of antibiotics) for two of three sampled residents:

1. Resident 154 for ceftriaxone (antibiotic used to treat bacterial infections)

2. Resident 29 for cephalexin (another antibiotic used to treat bacterial infections).

These deficient practices had the potential to increase antibiotic resistance and provide antibiotics without justification.

Findings:

1. During a review of Resident 154's Admission Record, the record indicated Resident 154 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including respiratory failure with hypoxia, tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).

During a review of Resident 154's Minimum Data Set (MDS-a resident assessment tool) dated 11/25/2024 indicated Resident 154's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was not intact and was dependent (required complete assistance of 2 or more helpers) for hygiene, bathing, and dressing.

During a review of Resident 154's physician order summary printed on 2/7/2025, the order indicated Ceftriaxone Sodium Solution Reconstituted 1 GRAM (GM-unit of measurement) Inject 1 GRAM intramuscularly every 24 hours for urinary tract infection (UTI - an infection in any part of the urinary system,

the kidneys, bladder or urethra) for 5 days.

2. During a review of Resident 29's Admission Record, the record indicated Resident 29 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including dementia and hypertension (HTN-high blood pressure).

During a review of Resident 29's MDS dated [DATE REDACTED] indicated Resident 29's was not intact, required supervision for eating, and required moderate assistance (helper provided less than half of effort) for hygiene, bathing, and dressing.

During a review of Resident 29's Medication Administration Record (MAR) printed on 2/7/2025, the MAR indicated Cephalexin Oral Tablet Give 500 Milligrams(MG-unit of measurement) by mouth four times a day for possible UTI for 7 days. The MAR indicated Resident 29 completed the ordered Cephalexin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 During a concurrent interview and record review on 02/06/25 at 2:50 p.m. with the Infection Preventionist Nurse (IPN), Resident 154 and Resident 29's charts: Level of Harm - Minimal harm or potential for actual harm 1. Resident 154's Infection Screening Evaluation dated 12/21/2024 was reviewed and indicated, No IPC Case Triggered. The IPN stated Resident 154's symptoms did not meet criteria, and there is no Residents Affected - Some documentation indicating the physician was notified. The IPN stated Resident 154 completed the ordered ceftriaxone.

2. Resident 29's Infection Screening Evaluation dated 1/17/2025 was reviewed. The Infection Screening Evaluation indicated, No IPC Case Triggered. The IPN stated Resident 29's symptoms did not meet criteria, and there is no documentation indicating the physician was notified.

The IPN stated the physician the physician should be notified if a resident does not meet Loeb's or Mc Geer's criteria.

During an interview on 2/8/2025 at 6:50 p.m. with the Director of Nursing (DON), the DON stated the purpose of the antibiotic stewardship program is to ensure antibiotics are used appropriately and prevent overuse or incorrect use of antibiotics. The DON stated the physician must be notified if a resident does not meet criteria.

During a review of the facility's Infection Control Preventionist Job Description dated 3/19/2024, the job description indicated, the IPN reviews every antibiotic order in the facility to ensure that each medication has proper indication for use and is appropriate for the residents and is responsible for sharing feedback to the physicians.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 50144

Residents Affected - Many Based on observation, interview and record review, the facility failed to offer, educate, and track coronavirus vaccinations for staff per facility's policy.

This failure had the potential to place all residents at risk for infection of coronavirus.

Findings:

During an interview on 2/6/2025 at 2:50 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated the facility does not have a tracking log or retain records of vaccination education, proof of vaccination, or declinations for coronavirus vaccination of facility staff.

During an interview on 2/8/2025 at 6:50 p.m. with the Director of Nursing (DON), the DON stated it is important to educate and document staff coronavirus vaccinations in order to protect residents and staff from

the coronavirus.

During a review of the facility's policy and procedure (P/P), titled Covid-19 Policy, dated 8/26/2024, the P/P indicated:

A. The facility will continue to educate residents, responsibility parties, and staff about the benefits of receiving the vaccination and risks of refusals.

B. Covid-19 2024-2025 vaccination will be offered to residents and staff based on recommendations by Long beach Health Department (LHD) and California Department of Health (CDPH).

C. The facility will keep copies of the proof of vaccinations.

E. The facility will continue to educate the resident, responsible party, and employees regarding the benefits of COVID-19 vaccination to keep their vaccination up to date unless it is contraindicated, refused by resident or refused by employees.

G. If am employee chooses not to be vaccinated, they must provide a written declination that he or she has declined the vaccination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page103of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Level of Harm - Minimal harm or potential for actual harm 45891

Residents Affected - Many Based on interview, and record review, The facility failed to provide Effective Communications training for direct care staff, including 18 of Registered Nurse (RN), 50 of Licensed vocational nurse (LVN), and 20 of Respiratory Therapist (RT) as required by the facility's policy and procedure (H&P).

This deficient practice had the potential to miscommunication, unmet resident needs, and compromised care, particularly for residents who rely on alternative communication methods.

Findings:

During an interview on 2/8/2025 at 6:56 p.m. with the Administrator, the ADM stated that currently, there were 18 of RN, 50 of LVN, 20 of RT, and 100 of CNA in the facility.

During a concurrent interview and record review on 2/8/2025 at 7:55 p.m. with the Director of Staff Development (DSD), the facility's in-service logs, for the year of 2024. The DSD stated that she was unaware that Effective Communications was a mandatory training for direct care staff and stated that the training was not provided in 2024. The DSD also stated that Effective Communications is important to ensure that staff can communicate effectively with residents, without this training, staff may lack the necessary skills to communicate properly with residents.

During an interview on 2/8/2025 at 8:05 p.m. with the Director of Nursing (DON), the DON stated that effective communication is essential to meet resident's need, particularly for Non-English speaking residents and those requiring specialized care, such as individuals with dementia, traumatic brain injury (TBI), or stroke, who rely on specific communication methods. The DON also stated that the training should be provided to ensure staff can effectively communicate with these residents, without proper training, resident's needs may not be met, affecting their care.

During a review of the facility's policy and procedure (H&P) titled, In-Service Training, All Staff, revised August 2022, indicated the all staff are required to participate in regular in-service education and primary object of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. The P&P also indicated 'Effective communication with residents and family as a required training topic for direct care staff. The P&P indicated that training requirement are met prior to staff providing services to residents, annually, and as necessary based on the facility's assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page104of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 45891

Residents Affected - Many Based on interview, and record review, The facility failed to provide Quality assurance and performance improvement (QAPI) training for direct care staff, including 18 of Registered Nurse (RN), 50 of Licensed vocational nurse (LVN), and 20 of Respiratory Therapist (RT) as required by the facility's policy and procedure (H&P).

This deficient practice had the potential to result in poor communication among staff, lack of awareness of facility updates, lack of collaborative work, and compromised resident care.

Findings:

During an interview on 2/8/2025 at 6:56 p.m. with the Administrator, the ADM stated that currently, there were 18 of RN, 50 of LVN, 20 of RT, and 100 of CNA in the facility.

During a concurrent interview and record review on 2/8/2025 at 7:55 p.m. with the Director of Staff Development (DSD), the facility's in-service logs, for the year of 2024, were reviewed. The DSD stated that

she was unaware that QAPI was a mandatory training for direct care staff, and she did not provide the training to direct care staff in 2024. The DSD also stated that QAPI training is important for staff to stay informed what was going on in the facility and could not answer the potential outcomes of not providing the training.

During an interview on 2/8/2025 at 8:05 p.m. with the Director of Nursing (DON), the DON stated that QAPI is ongoing process used to address issues, improve communication among staff, ensure proper resident care. Without this training, staff may not be aware of updated facility procedures, proper communication protocols, or how to assist residents effectively, potentially impacting resident care and teamwork within the facility.

During a review of the facility's policy and procedure (H&P) titled, In-Service Training, All Staff, revised August 2022, indicated the all staff are required to participate in regular in-service education and primary object of the in-service training is to ensure that staff are able o interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. The P&P also indicated 'Elements and goals of the facility QAPI program as a required training topic. The P&P indicated that training requirement are met prior to staff providing services to residents, annually, and as necessary based on the facility's assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page105of105 056043

F-F865)

Level of Harm - Immediate Findings: jeopardy to resident health or safety During a review of Resident 188's Admission Record, the Admission Record indicated Resident 188 was admitted to the facility 12/6/2024 with diagnoses including muscle wasting (the shrinking and weakening of Residents Affected - Few muscles), non-Hodgkin lymphoma (cancer [invasive growth of disease causing organisms]), tracheostomy tube (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and multiple pressure ulcers (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) and had a GT.

During a review of Resident 188's Minimum Data Set ([MDS] a resident assessment tool) dated 12/13/2024,

the MDS indicated Resident 188 had severe cognitive impairment (a significant decline in cognitive abilities that significantly impact daily functioning and independence) for daily decision making. The MDS indicated Resident 188's current weight as of 12/6/2024 was 119 lbs. The MDS indicated Resident 188 was receiving

a therapeutic (a meal plan that controls the intake of certain foods or nutrients) diet and was receiving 51% or more of his total calories through a feeding tube.

During a review of Resident 188's untitled Care Plan initiated on 12/23/2024, the Care Plan indicated Resident 188 had cancer with an increased risk for weight loss secondary to non-Hodgkin's lymphoma. The untitled Care Plan indicated Resident 188's goal was not to have a weight loss exceeding 5% per month.

The Care Plan interventions included RD evaluations and to notify the physician and Resident 188's responsible party of any change of conditions.

During a review of a document titled, Weekly-Weights- Station Subacute (a level of care needed by a patient who does not require hospital level acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) Summary dated 12/2024, the document indicated Resident 188's admitting weight was 119 lbs. and was weighed weekly after admission

on 12/6/2024. Resident 188's weight was as follows:

1. On 12/11/2024 Resident 188's weight was 115 lbs. There was four lbs. weight loss in five days since admission on12/6/2024.

2. On 12/18/2024 Resident 188's weight was 112 lbs. There was another three lbs. weight loss in a week from 12/11/2024.

3. On 12/27/2024 Resident 188's weight was 110 lbs. There was another two lbs. weight loss in a week from 12/28/2024.

4. On 1/3/2025 Resident 188's weight was 110 lbs.

The Weekly Weights and Vitals Summary did not indicate the aforementioned weekly weights were recorded and addressed in Resident 188's electronic medical record (EMR) and the resident's weekly weight loss was addressed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During a review of Resident 188's Weights and Vitals Summary, dated 12/6/2024, the Weekly Weights and Vitals Summary indicated Resident 188 weighed 119 lbs. The Weights and Vitals Summary dated 1/3/2025 Level of Harm - Immediate indicated Resident 188's weight was 110 lbs., a nine lbs. (7.6%) weight loss since admission. The Weights jeopardy to resident health or and Vitals Summary did not indicate Resident 188's weekly weight measurements were continued when the safety weight loss was identified on 1/3/2025.

Residents Affected - Few During a review of Resident 188's Weights and Vitals Summary dated 2/6/2025, the Weights and Vitals Summary indicated Resident 188 weighed 93.2 lbs., which was a 25.8 lb. (21.7%) weight loss since admission.

During a review of Resident 188's Order Summary Report (physician's orders), the Order Summary Report indicated an order was placed on 12/6/2024 to monitor Resident 188's weight weekly for four weeks and then monthly. The Order Summary Report indicated an order for monthly weights was placed on 12/6/2024.

The Order Summary Report indicated there was an order placed on 12/6/2024 for GT feeding with Glucerna (diabetes-specific nutritional formula) 1.5 calorie ([cal] a unit of energy derived from nutrition) at 45 cubic centimeters (cc) per hour (hr) for 20 hours via GT pump (device to administer feeding formula) to provide 900 cc equal to1350 kilocalories (kcals) per day and discontinued on 1/7/2025.

During a review of Resident 188's change of condition (COC)- Licensed Nurse Note dated 12/14/2024, the note indicated Resident 188 was having frequent loose stools (diarrhea).

During review of Resident 188's Order Summary Report the Order Summary Report indicated on 1/7/2025,

an order was placed for Imodium A-D (antidiarrhea medication) 2 milligrams (mg) via GT every four hours as needed for loose stool for seven days.

During a review of Resident 188's Nutrition/ Dietary Note dated 1/7/2025 at 10:56 a.m., the Nutrition/Dietary Note indicated the RD documented Resident 188's weight was 110 lbs. with a nine lbs. weight loss in one month. The RD documented Resident 188's ideal body weight ([IBW] the healthiest weight per height) range was 117 lbs. to 143 lbs., and Resident 188's nine lbs. weight loss was significant. The Nutrition/Dietary Note indicated the RD recommended to increase the Glucerna 1.5 from 45 cc/hr to 55 cc/hr to provide 1100cc/1650 kcal per day. The Nutrition/Dietary Note indicated the RD recommended to monitor the resident's weight trends (frequency not specified) and she (RD) documented she would reassess the resident's nutritional needs as needed. There was an addendum (additional information) added on 1/7/2025 to the Nutrition/ Dietary Note indicating Resident 188 was able to tolerate the GT feeding well and had no nausea (feeling sick to your stomach), vomiting (throwing-up forces the contents of the stomach up through

the food pipe) or diarrhea.

During a review of Resident 188's Nutrition/ Dietary Note dated 1/7/2025 at 1:13 p.m., the Nutrition/ Dietary Note indicated the RD discussed Resident 188's frequent loose stools with a nurse (unknown) and to hold

the order to increase the GT feeding to 55 cc/hr due to Resident 188's diarrhea. The Nutrition/ Dietary Note indicated the GT feeding would be increased once the diarrhea resolved.

During a review of Resident 188's Medication Administration Record (MAR) for January 2025, the MAR indicated Imodium A-D was last given to the resident on 1/13/2025 for loose stool.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During a review of Resident 188's Order Summary Report for January 2024, the Order Summary Report indicated an order dated 1/7/2025 to increase Glucerna 1.5 to 55 cc/hr. to administer for 20 hours via GT Level of Harm - Immediate pump to provide 900 cc/1350 kcal per day. This order was discontinued three days later on 1/10/2025. The jeopardy to resident health or Order Summary Report indicated on 1/10/2025 an order was placed to decrease the Glucerna 1.5 back safety down to 45 cc/hr to administer for 20 hours to provide 900 cc/1350 kcal per day. The Order Summary Report indicated there were no new orders placed until 2/7/2025. On 2/7/2025 there was a new order to increase the Residents Affected - Few GT feeding with Glucerna 1.5 at 55 cc per hour for 20 hours via GT pump to provide 1100 cc/1650 kcal per day.

During a review of Resident 188's Licensed Nurses Progress Notes dated 1/7/2025, the Licensed Nurses Progress Notes indicated Resident 188's physician (MD 1) was informed Resident 188 was having loose stool and the RD recommended to increase Resident 188's GT water flush (water given through the GT for hydration) to 50cc/hr related to elevated (no result specified) blood urea nitrogen ([BUN] a kidney function laboratory test). The Licensed Nurses Progress Notes did not indicate MD 1 was informed of Resident 188's nine lbs. weight loss.

During a review of Resident 188's Care Plan (untitled) initiated on 1/7/2025, the Care Plan indicated Resident 188 was identified to be at risk for dehydration secondary to diarrhea. The Care Plan indicated the goal for Resident 188 was to reduce the risk of unplanned weight changes. The Care Plan interventions included monitoring Resident 188's weight (frequency not identified) and report (unspecified to whom) any change of plus or minus (+/-) of three pounds per week or +/- five pounds per month per policy (policy not identified). This Care Plan did not include Resident 188's actual weight loss of 7.5% (nine lbs.) that had been identified on 1/3/2025 or the interventions to reduce the risk of continued weight loss from occurring.

During a concurrent observation and interview on 2/5/2025 at 12 p.m., with Resident 188, in Resident 188's room, the resident was observed receiving Glucerna 1.5 through GT at rate of 45 cc/hr. Resident 188 stated

he had been losing weight recently but was hopeful he would gain some weight back because he passed his swallow evaluation (checks how well a resident swallows) on 2/4/2025 and was now able to eat a little food along with his tube feeding for oral gratification (the pleasure derived from oral activities such as eating). Resident 188 stated he hoped to gain some weight because his legs looked like bones. Resident 188 was observed pulling his bed sheets away from his legs. Resident 188 legs were observed being very thin with prominent bones. Resident 188 stated he wanted to be stronger to participate in therapy.

During an interview on 2/5/2025 at 12:03 p.m., Licensed Vocational Nurse (LVN) 6 stated RNA 1 was responsible for measuring and recording weights. LVN 6 stated RNA 1 had not reported any recent weight changes for Resident 188.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 2/5/2025 at 2:49 p.m., Registered Nurse (RN) 2 stated as of 2/5/2025, the last weight recorded for Resident 188 was on 1/3/2025. RN 2 stated RNA 1 was supposed to turn monthly weights in by Level of Harm - Immediate the fifth day of every month but they were not yet completed. RN 2 stated the facility usually did not complete jeopardy to resident health or a COC for weight loss unless it was a lot of weight, like a 40 lbs. weight loss. RN 2 agreed that a nine lbs. (7. safety 6%) weight loss was a lot of weight to lose in one month. RN 2 stated that a COC did not need to be completed for a 7.5% weight loss. RN 2 stated if Resident 188 had been weighed weekly for four weeks after Residents Affected - Few he was admitted on [DATE REDACTED], per physician's order, the RD could have assessed Resident 188 sooner than 1/7/2025 and identified the gradual weight decrease. RN 2 stated she reviewed Resident 188's electronic medical record and could not find any documentation that Resident 188 was weighed weekly as RD recommended.

During an interview on 2/6/2025 at 10:22 a.m., RNA 1 stated she weighed Resident 188 on Friday 1/31/2025 and the resident weighed 95 lbs. RNA 1 stated she did not document the weight for 1/31/2025 in Resident 188's chart but I knew Resident 188 had lost a lot of weight so she (RNA 1) verbally informed RN 3 about the weight loss on 1/31/2025. RNA 1 stated RN 3 stated that the weight loss identified on 1/31/2025 was okay, and that Resident 188 would start gaining weight because he passed his swallow evaluation and was able to eat (for oral gratification) as well as receive tube feedings. RNA 1 could not produce any documentation that

the resident's weight of 95 lbs. on 1/31/2025 was documented. RNA 1 pointed to her head and stated, it is all

in here. RNA 1 stated the residents' monthly weights on the sub-acute unit were not entered into the computer yet because she had yet to complete taking all the weights for the month and would finish by 2/7/2025.

During an interview on 2/6/2025 at 11:48 a.m., RN 3 stated on 1/31/2025, RNA 1 did inform her Resident 188 lost a lot of weight (did not know exact amount). RN 3 stated she did not inform the physician because

she was admitting another resident at the time. RN 3 stated she assumed Resident 188 would start gaining weight now that he was able to eat by mouth and was continuing to receive tube feeding. RN 3 stated Resident 188's diarrhea had stopped sometime mid-January 2025 (exact date unknown).

During an observation on 2/6/2025 at 12:02 p.m., RNA 1 and LVN 3 were observed weighing Resident 188 using a mechanical lift (device used to assist with transfers [from one surface to another] and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) containing a scale. Resident 188 weighed 93.2 lbs. (total of 25.8 lbs. weight loss from admission weight of 119 lbs. on 12/6/2024).

During an interview on 2/6/2025 at 12:21 p.m., the RD stated the nursing staff did not notify her of Resident 188's identified weight loss on 1/3/2025. The RD stated residents' monthly weights were documented in the residents' medical records and were printed out for her review every Monday or Thursday (in general). The RD stated on 1/7/2025, she reviewed Resident 188's weight report dated 1/3/2025 which indicated the resident weighed 110 lbs. and had a weight loss of nine lbs. The RD stated she assessed Resident 188 on 1/7/2025. The RD stated she had not reassessed Resident 188 since 1/7/2025 (30 days ago) when she evaluated him for significant weight loss and did not implement any interventions such as measuring his weight weekly because she (RD) did not feel Resident 188 required weekly weights for close monitoring. The RD stated she was unable to increase Resident 188's GT feeding on 1/7/2025 because Resident 188 had diarrhea. The RD stated she did not reassess Resident 188 after the diarrhea subsided on 1/13/2025. The RD stated she did not feel it was necessary to monitor Resident 188's significant weight loss of 7.6% more frequently than monthly. The RD stated it was important to monitor severe weight loss closely to ensure the residents health status did not decline. The RD stated the potential outcome of severe weight loss was malnutrition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 2/6/2025 at 2:04 p.m., MD 1 stated he should have been notified as soon as possible of Resident 188's severe weight loss. MD 1 stated it was important he was notified so he could decide on Level of Harm - Immediate new interventions and ensure the RD was assessing the resident's nutritional needs. jeopardy to resident health or safety During a review of Resident 188's Nutrition/ Dietary Note dated 2/6/2025, the Nutrition/ Dietary Note indicated Resident 188 weighed 93 lbs., and had a 17 lbs. (15%) weight loss in one month from 1/3/2025 to Residents Affected - Few 2/6/2025 and had 26 lbs. weight loss in three months from 12/6/2025 to 2/6/2025. The Nutrition/ Dietary Note indicated the weight loss was significant and was likely related to pressure ulcer healing, diarrhea, and respiratory failure (a serious condition that makes it difficult to breathe on your own). The Nutrition/ Dietary Note indicated Resident 188 was tolerating GT feeding well and was not experiencing diarrhea at the time on 2/6/2025. The Nutrition/ Dietary Note indicated the RD recommended to increase the GT feeding to Glucerna 1.5 at 55cc/hr for 20 hrs. to provide 1100 cc/1650 kcal daily.

During a review of Resident 188's COC/ Interact Assessment form (SBAR) dated 2/7/2024, the COC indicated Resident 188 had a 26 lbs. weight loss. The COC indicated MD 1 was notified of the weight loss.

During a review of Resident 188's COC/ Interact Assessment forms (SBAR), the COC/Interact Assessment forms did not indicate there were any other COCs from admission (on 12/6/2024) to 2/7/2025 in Resident 188's chart regarding weight loss or that MD 1 or Resident 188's responsible party (RP), family member (FM)1were informed of the resident's severe weight loss.

During an interview on 2/7/2025 at 12:41 p.m., Resident 188's FM 1 stated nursing staff (unknown) told her

in passing Resident 188 was losing weight, but no one informed her how much weight. FM 1 stated on 2/7/2025, the morning nurse (unknown) called her about Resident 188's weight loss and informed her that Resident 188 had lost weight. FM 1 stated they did not inform her of the actual amount of weight he lost but now she was feeling worried about Resident 188's health.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 2/8/2025 at 1:23 p.m., the ADON stated a COC was important documentation including monitoring when an issue outside of the resident's baseline occurred. The ADON stated a Level of Harm - Immediate significant weight loss was outside of Resident 188's baseline and a COC should have been initiated. The jeopardy to resident health or ADON stated he reviewed Resident 188's medical record and did not find a COC completed for weight loss safety or any documentation indicating the physician or FM 1 was notified of the weight loss. The ADON stated the RD needed to be made aware of significant weight loss but so did the physician because the physician had Residents Affected - Few more options for addressing the weight loss, more interventions, and modalities to address the weight loss.

The ADON stated a care plan should have been created for the weight loss as a change of condition. The ADON stated it was important to create a care plan, so all staff involved knew the new interventions, new goals, and the problem the resident was having. The ADON stated he reviewed Resident 188's medical

record and did not find a care plan for the resident's severe weight loss. The ADON stated it was important to monitor interventions for a COC to see if interventions were effective. The ADON stated the IDT should have met and discussed Resident 188's weight loss so that they could collaborate and come up with new solutions for the weight loss and recommend them to the physician. The ADON stated the IDT was to be done as soon as the RP and resident were available to be involved in the care planning. The ADON stated as soon as Resident 188's diarrhea subsided on 1/13/2025 the RD should have reassessed the resident and the physician should have been notified so they could decide if GT feeding could have been increased. The ADON stated the potential outcome of not monitoring severe weight loss or reassessing the resident's interventions was further weight loss. The ADON stated based on Resident 188's current weight of 93.2 lbs.,

the interventions were not working and the IDT meeting should have been conducted to address the resident's progressive weight loss.

During an interview on 2/8/2025 at 1:57 p.m., the RD stated she did not attend IDT meetings for weight loss.

The RD stated the IDT discussed Resident 188's case but the notes of the IDT discussion were not written down. The RD stated if it was not documented, it was not done. The RD stated RNA 1 did not write down any weights on 1/31/2025, she (RNA 1) just told her (RD) the weight verbally on 2/6/2025. The RD stated the potential outcome of not being notified right away of weight loss was a delay of interventions to prevent further weight loss. The RD stated she based her assessment of Resident 188's chart and information obtained from nurses but did not assess or speak to the resident himself.

During an interview on 2/8/2025 at 2:33 p.m., the DON stated facility staff cannot assume a weight loss was expected based on the resident's diagnosis. The DON stated they must closely monitor the resident's weight trends (via weekly weights) to see if any other interventions could be implemented for the resident. The DON stated she was not made aware Resident 188 had severe weight loss and that his weight loss was not discussed during an IDT meeting. The DON stated communication among the care team was important so weights can be addressed appropriately. The DON stated it was important to reassess the interventions to see if the interventions were working and revise and add new interventions as needed.

During an interview on 2/8/2025 at 3:02 p.m., the director of staff development (DSD) stated the weights should be documented in the resident's chart right away after obtaining the weight. The DSD stated, we are all human and the RNAs could forget a weight or mix up the weights of different residents if they did not write them down right away. The DSD stated accurate weights were important so an accurate nutritional assessment could be done, and weights could be accurately monitored.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 2/8/2025 at 3:26 p.m., the medical director (MD 2) stated the physician needed to be informed as soon as weight loss was identified. MD 2 stated any significant weight fluctuations needed to be Level of Harm - Immediate addressed. MD 2 stated continued weight loss was not good and affected a resident's well-being, could lead jeopardy to resident health or to malnutrition and slow pressure sore healing. safety

During a review of the facility's policy and procedure (P/P) titled Nutritional assessment dated ,d+[DATE REDACTED], the Residents Affected - Few P/P indicated as part of the comprehensive assessment, the nutritional assessment was to be a systematic, multidisciplinary process that included gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk of impaired nutrition.

During a review of the facility's P/P titled Weight Assessment and Intervention dated 3/2022, the P/P indicated weights were to be recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since last weight assessment was retaken the next day for confirmation and if the weight is verified, the nursing team was to immediately notify the RD in writing. Residents were to be weighed at an interval determined by the IDT. The threshold for significant unplanned and undesired weight loss was to be based on the following criteria [ where percentage of body weight loss = (usual weight - actual weight)/ (usual weight) x 100]:

a. 1 month - 5% weight loss is significant; greater than 5% is severe.

b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe.

c. 6 months - 10% weight loss is significant; greater than 10% is severe.

Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate (RP). Individualized care plans shall address to the extent possible: the identified causes of weight loss; goals and benchmarks for improvement; and time frames and parameters for monitoring and reassessment.

During a review of the facility's P/P titled Change in Resident's Condition or Status dated 3/2022, the P/P indicated the nurse was to notify the physician and RP when there has been a significant change in the resident's physical condition. Notifications were to be made within 24 hours. The nurse was to record information relative to changes in the resident's record.

During a review of the facility's Registered Dietician (RD) Consultant job description dated 4/2022, the job description indicated the RD was to work with the ADM, nursing, and other department heads on planning resident care issues, and quality assessment monitoring and reporting. The RD was responsible for evaluating the nutritional needs of the residents and documenting in the nutritional record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46415

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure tube feedings were properly managed for three (3) of four (4) sampled residents (Resident 16, 84, and 37) with a gastrostomy tube (GT or g-tube: a tube that is passed through the abdominal wall to the stomach used to provide nutrition) by failing to:

1. Ensure Resident 16's tube feeding was disconnected after the administration of feeding.

2. Ensure the feedings were replaced in a timely manner for Residents 84 and Resident 37 that were hanging and were not administered for more than 24 hours (hrs) later.

These deficient practices had the potential to place Residents 16, 84, and 37 at risk for infection.

1. During a review of Resident 16's Admission Record, the Admission Record indicated Resident 16 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including GT, chronic obstructive pulmonary disease (COPD: a chronic lung disease causing difficulty in breathing), gastroesophageal reflux disease (GERD: stomach acid that flows back from the stomach into the tube that connects the mouth and stomach), and chronic kidney disease (moderate damage to the kidneys).

During a review of Resident 16's History and Physical (H&P) dated 6/15/2024, the H&P indicated Resident 16 did not have the capacity to understand and make decisions.

During a review of Resident 16's Minimum Data Set ([MDS] a resident assessment tool)], dated 11/8/2024,

the MDS indicated Resident 16's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were severely impaired. The MDS indicated Resident 16 was dependent in all aspects of activities of daily living (ADL: bathing, sit to lying, personal, toileting, oral hygiene, and eating. The MDS indicated Resident 16 was impaired on both the upper (arms/shoulders) and lower (hips/legs) extremities.

During a review of Resident 16's Order Summary (physician notes) dated 2/5/2025, the physician notes indicated (Nepro: therapeutic nutrition designed for people who have reduced kidney function) at 50 cubic centimeter (cc: unit of volume that measures space occupied by solid or liquid) per hour (hr.) for 20 hours (hrs.) via pump to provide 1000CC/1800 kilocalories (kcals: unit measurement of energy used to describe calorie content of food) per day with an active date of 6/12/2024.

During a concurrent observation and interview on 2/3/2025 at 11:14 a.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated Resident 16's tube feeding was not turned on but it was still connected to Resident 16's g-tube. LVN 5 stated anything can happen to the G-tube or the resident whether the tube feeding is running or not. LVN 5 stated if the resident does not get up, the feeding tube stayed connected to Resident 16.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 During an interview on 2/8/2025 at 7:07 p.m. with Director of Nursing (DON), the DON stated the feeding tube should not be attached to the resident if the feeding is done or empty. The DON stated it can create Level of Harm - Minimal harm or more problems such as abdominal distention (feeling of fullness and swelling in the abdomen), air, and potential for actual harm restlessness (inability to relax) for Resident 16.

Residents Affected - Some 2. During a review of Resident 84's Admission Record, the Admission Record indicated Resident 84 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including gastrostomy, gastroparesis (condition where the stomach muscles do not work to move food to be digested), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebrovascular disease (CVD: condition that affect the blood vessels in brain) affecting left non-dominant side.

During a review of Resident 84's H&P dated 5/2/2024, the H&P indicated Resident 84 does not have the capacity to understand and make decisions.

During a review of Resident 84's MDS dated [DATE REDACTED], the MDS indicated Resident 84's cognitive skills were intact. The MDS indicated Resident 37 was dependent in performing a majority of ADL's and required maximal assistance for oral hygiene. The MDS indicated Resident 84 was impaired on both the upper and lower extremities.

During a review of Resident 84's physician notes dated 2/6/2025, the physician notes indicated Jevity 1.5 (calorie dense and fiber fortified formula that provides a balanced nutrition for long- or short-term use of tube feeding) at 45cc/hr. for 20hrs via pump to provide 900cc/1350kcal per day with an active date of 1/29/2024.

During an observation on 2/3/2025 at 3:10 p.m., in Resident 84's room, the Jevity 1.5 that was dated 2/2/2025 at 12 (did not indicate a.m. or p.m.) was running at 45cc/hr. The Jevity had about 700mililiter (mL: unit of volume) left to infuse.

During an observation on 2/4/2025 at 9:39 a.m. in Resident 84's room, the Jevity 1.5 that was dated 2/2/2025 at 12 (did not indicate a.m. or p.m.) was turned off and was empty.

During a concurrent observation and interview on 2/4/2025 at 9:57 a.m., with the DON, the DON stated the Jevity 1.5 feeding was dated 2/2/2025 at 12:00 and does not know if it was in the a.m. or p.m. The DON stated the staff should have hung another container of Jevity and changed the tube feeding yesterday (2/3/2025). The DON stated the tube feeding was finished, and it has been hanging for 48 hours. The DON stated the Jevity 1.5 feed label indicated that it should not be hung for more than 24 hours. DON stated tube feedings must be changed per manufacturers instructions, as it may cause gastrointestinal (conditions affecting the digestive system) problems and diarrhea if the resident received a feeding that was hanging over 48 hrs.

3. During a review of Resident 37's Admission Record, the Admission Record indicated Resident 37 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] and with diagnoses including hypertension (high blood pressure), gastrostomy, and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) on the left elbow and hand.

During a review of Resident 37's H&P dated 12/19/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 During a review of Resident 37's MDS dated [DATE REDACTED], the MDS indicated Resident 37's cognitive skills were moderately impaired. The MDS indicated Resident 37 was dependent on all aspects of ADL. The MDS Level of Harm - Minimal harm or indicated Resident 37 utilized a wheelchair and have impairments on both the upper and lower extremities. potential for actual harm

During a review of Resident 37's physician notes dated 2/6/2025, the physician notes indicated Jevity 1.5 at Residents Affected - Some 45cc/hr. for 20 hrs via pump to provide 900cc/1350kcal per day (on at 12:00 p.m. and off at 8:00a.m. of until dose limit is completed) with an active date of 1/29/2025.

During a concurrent observation and interview on 2/3/2025 at 3:36 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 37's tubing for the tube feeding was wrapped around the right side of the residents side rails and the tube was taught. LVN stated he changes tube feeding within 48 hrs and is in the facility policy. LVN 2 stated Resident 37's tube feeding that is hanging was dated 2/2/2025 at 5:00 a.m. and indicated it should have been replaced as the feeding can go bad and is a safety concern. LVN 2 stated the water bag does not have a label on it, and they would normally label it. LVN 2 stated the water bag should have been replaced as it is replaced every 24 hours.

During a review of the facility's policies and Procedures (P&P), titled Enteral Feedings-Safety Precautions, revised 11/2018, the P&P indicated the facility will remain current in and follow accepted best practices in enteral nutrition. Change administration sets for open-system enteral feedings at least every 24 hours, or as specified by the manufactured. Change administration sets for closed-system enteral feeds in according the manufacturer's instructions.

During a review of Jevity 1.5 Cal Complete, Balanced Nutrition with Fiber manufacturer guideline, updated 7/22/2024, the manufacturer guideline indicated unless a shorter hang time is specified by the set manufacturer, hand product for up to 48 hours after initial connection when clean technique and only one new set are used. Otherwise hang for no more than 24 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of105 056043 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056043 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Care Center 1913 E 5th Street Long Beach, CA 90802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 45891

Residents Affected - Some Based on interview and record review the facility failed to

1. Ensure Restorative Nurse Assistant (RNA 1) was competent regarding documenting residents' weight in

the resident's medical record and licensed nurses (unknown) including Registered Nurses (RN 2 and RN 3) were competent in reporting changes of condition related to weight loss to the registered dietician (RD), physician (MD 1), and the responsible party (Family Member (FM)1) for one of 10 sampled residents (Resident 188).

These deficient practices had the potential to cause inaccurate nutrition assessments and the potential for a delay in care and implementation of interventions to prevent further weight loss for Resident 188.

Cross reference: