Intercommunity Care Center

During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/26/2024, the MDS indicated Resident 1's cognition was severely impaired.

The MDS indicated Resident 1 had the ability to understand and be understood by others.

The MDS indicated Resident 1 had hallucinations (seeing and hearing things that are not there) and delusions (false belief).

During a review of Resident 1's undated Situation Background Assessment Recommendation ([SBAR] a form of communication between members of a health care team), the SBAR indicated on 8/18/2024 at approximately 8 a.m., Resident 1 was involved in a resident to resident physical altercation with injury.

The SBAR indicated Resident 1 was noted to have purple discoloration to the bridge of her nose, with epistaxis (nose bleed) and deviation (shifted to one side) with pain rated a 10 out of 10 (an 11 eleven point scale where pain in rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain).

During a review of Resident 1's Nurse Progress note, dated 8/18/2024 and timed at 8:45 a.m., the Nurse Progress note indicated at 8:05 a.m., on 8/18/2024, Resident 1 was observed sitting on a bench close to a Resident (Resident 2).

The Nurse Progress note indicated Resident 1 told Resident 2 to stay away from her, don't move any closer and then elbowed Resident 2, Resident 2 then elbowed Resident 1 in her nose.

555823

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555823 B.

Wing 08/23/2024

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

Intercommunity Care Center 2626 Grand Avenue Long Beach, CA 90815