Intercommunity Care Center

F-F600

Findings:

During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including dementia (loss of thinking, remembering, reasoning), bipolar disorder (mental disorder that causes a shift in mood and behavior) and schizophrenia ( mental disorder that affects how someone thinks, feels, behaves).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 555823 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0867 During a concurrent observation and interview on 8/22/2024 at 8:30 a.m., Resident 1 was observed in her room with yellowish-bluish discoloration on the bridge of her nose, and on both of he checks extending under Level of Harm - Minimal harm or both of her eyes. Resident 1 stated she was punched in the face the other day (8/18/2024) by Resident 2. potential for actual harm

During an interview on 8/22/2024 at 1:47 p.m., Certified Nurse Assistant (CNA) 1, stated she was assigned Residents Affected - Few to monitor the patio on 8/18/2024. CNA 1 stated the monitor sits at the exit at the top of the stairs looking down on the patio area. CNA 1 stated on 8/18/2024 at approximately 8 a.m., she observed Resident 1 and Resident 2 sitting on a bench less than an arms' length apart. CNA 1 stated there were usually two staff members assigned to monitor the patio because the patio was large area and there were areas that were hidden from view . CNA 1 stated she observed and heard Resident 1 tell Resident 2 to move away, when Resident 2 did not comply, Resident 1 elbowed Resident 2 who then reacted by elbowing Resident 1 in the nose. CNA 1 stated she does not remember receiving an in-service or training within the last few months pertaining to abuse or abuse reporting.

During an interview on 8/23/2024 at 9:43 a.m., Registered Nurse (RN) 1, stated he was the supervising nurse on 8/18/2024, and at approximately 8 a.m., CNA 1 called him to the patio to assess Resident 1. RN 1 stated he observed Resident 1 with blood running from her nose, a purple discoloration on the bridge of her nose and her nose appeared to be deviated toward one side of her face. RN 1 stated he was not familiar with how to fax or call the CDPH and he had not received an in-service or training on the facility's abuse reporting process.

During a review of the facility's Plan of Correction (POC) for the abbreviated survey completed on 5/28/2024,

the POC indicated the facility would randomly check with the Director of Staff Development (DSD) to ensure

the lesson plan of Abuse Mandatory Reporting was scheduled for all staff, and any non-compliance with the Abuse Investigation and Reporting policy would be reported to their UR/CQI committee on a quarterly basis for recommendation and or correction.

During an interview on 8/23/2024 at 3:10 p.m., the DON stated she did not report the incident of abuse immediately nor within 2 hours because she was busy attending to the needs of Resident 1 and Resident 2.

The DON stated failure to report abuse can causes a delay in the investigation of the CDPH and is a violation of the federal regulations. The DON stated she was not aware of a POC or QAPI discussions related to abuse prevention or reporting and had just began working as the DON in the facility 7/2024.

During an interview on 8/23/2024 at 3:15 p.m., the Administrator (ADM) stated he was not available to complete the reporting process on 8/18/2024 due to personal circumstances and he was not aware the incident of abuse was not reported to CDPH until 8/18/2024 at 11:55 p.m. The Administrator stated the facility was in violation of their policy and Federal regulations for not reporting the alleged incident of abuse between Resident 1 and Resident 2 within two hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 555823 Department of Health & Human Services Printed: 09/12/2025 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 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

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 0867 During a concurrent interview and record review on 8/23/2024 at 3:30 p.m., with the Administrator, the facility's QAPI meeting minutes dated 7/9/2024 was reviewed. The QAPI minutes agenda indicated the topic Level of Harm - Minimal harm or of abuse to be discussed, however, abuse was not discussed during the QAPI meeting. The ADM stated the potential for actual harm QAPI meeting should have included a discussion pertaining to the facility's status in Abuse training, reporting and tracking but they did not have the time to fit it into the QAPI meeting. The Administrator stated he did not Residents Affected - Few ensure continued oversight of the facility's POC of the deficient practices identified during the previous abbreviated survey (5/28/2024) which ensured staff was educated and in serviced on the facility reporting policy. The Administrator stated he failed to present the new facility abuse policy titled Abuse reporting and Response dated 8/1/2024 to the DON. The Administrator stated failure to discuss and collaborate with the QAPI team, issues pertaining to abuse put the residents at risk for further occurrences and did not provide for an effective QAPI committee.

During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance (QAPI) Committee, revised 4/2014, the P/P indicated the facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI program. The P/P indicates the Administrator shall delegate the necessary authority of the QAPI committee to establish, maintain, and oversee the QAPI program. The P/P indicates the primary goals of the QAPI committee are to establish , maintain, oversee facility systems and processes to support the delivery of quality of care and services, promote the consistent use of facility systems and processes during the provision of care and services, help identify actual and potential negative outcomes relative to resident care and resolve them appropriately, support the root cause analysis to help identify where patterns of negative outcomes point to underlying systemic problems, help departments, consultant and ancillary services implement systems to correct potential and actual issues in quality of care, coordinate the development , implementation, monitoring an evaluation of performance improvement projects to achieve specific goals, coordinate and facility communication regarding the delivery of quality resident care within and among departments and services, between facility staff , residents and family members.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 555823