North Long Beach Post Acute
North Long Beach Post Acute in LONG BEACH, CA — inspection on June 28, 2024.
Found 26 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an observation on 6/26/2024 at 8:35 a.m. in Resident 61's bedroom, Resident 61 was lying
Nursing (DON) and Central Supply (CS) came to Resident 61's bedside to assist Resident 61 with turning toward the left. Resident 61 asked the DON and CS to be careful with the left arm due to pain.
During an interview on 6/26/2024 at 9:37 a.m. with CS, CS stated she was also a Certified Nursing Assistant (CNA). CS stated Resident 61 was repositioned to turn toward the left side. CS stated Resident 61 had pain in the left arm because of the left arm contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), which CS stated was positioned abnormally.
During an observation on 6/26/2024 at 1:37 p.m. with the Director of Rehabilitation (DOR) in Resident 61's room, Resident 61 was lying in bed wearing a hospital type gown with the left arm positioned on the side of the body.
During a concurrent observation and interview on 6/27/2024 at 1:20 p.m. with Resident 61 in Resident 651's room, Resident 61 was lying awake in bed wearing a hospital type gown with the left arm positioned directly to the side of Resident 61's body. Resident 61 stated the left arm had some pain at rest that sharply increased when someone touched or moved the left arm for exercises. Resident 61 stated he would like to wear my own clothes, like sweatshirts and sweatpants, not hospital type clothes. Resident 61 provided permission to look in the closet directly across from Resident 61's bed. Resident 61's closet was full of clothes, including but not limited to 27 shirts, two pairs of pants, and one pair of shorts.
During an interview on 6/27/2024 at 1:42 p.m. with Certified Nursing Assistant 5 (CNA 5) and Resident 61 in Resident 61's room, CNA 5 stated Resident 61 was dressed in a hospital type gown because Resident 61 had pain in the left arm, preventing Resident 61 from putting on a shirt. CNA 5 stated Resident 61 did not like to get out of bed because Resident 61 felt pain throughout the body. Resident 61 stated the left arm pain prevented Resident 61 from getting dressed and getting out of bed.
During an interview on 6/28/2024 at 11:56 a.m. with the DON, the DON stated the facility was the resident's home and residents were dressed in regular clothes to promote dignity (state of being worthy of honor or respect).
During a review of the facility's policy and procedure (P&P) titled, Dignity, the P&P indicated each resident Shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth.
The P&P indicated the Residents were treated with dignity and respect at all times, including encouraging residents to dress in clothing that they prefer.
Cross Reference F-F688
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During an interview on 06/24/2024 at 2:13 p.m., the Director of Staff Development (DSD) stated if resident cannot reach the call light to call for help, resident can become restless and frustrated and will feel like less of a person and needs are not met. DSD stated if resident was unable to call for assistance there was potential for fall and injury if resident will try to reach the call light.
During the review of facility's policy and procedure (P&P) titled Answering the Call Light revised on 09/2022, indicated The purpose of this procedure was to ensure timely responses to the resident's requests and needs.
Ensure that the call light was accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a review of Resident 102's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 102 tolerated wearing the left knee extension (straightening out the knee) splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four hours.
The PT Discharge Summary also indicated the RNA, provided a 100 percent (%) return demonstration for exercises to both legs, including right leg active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) exercises and left leg PROM exercises with left knee splint application.
The PT Discharge Summary recommendations indicated for the RNA to provide right leg AROM, left leg PROM, and application of the left knee extension splint for four hours as tolerated.
During a review of Resident 102's Rehab Screening, dated 4/5/2024 written by PT 1, the Progress Note for Rehab Screening indicated Resident 102's ROM in the right leg was within functional limits (WFL, sufficient movement without significant limitation).
The Rehab Screening indicated both of Resident 102's arms and the left leg was impaired (unspecified).
The Rehab Screening indicated Resident 102 had a significant decline with mobility, ROM, and ADLs.
During a review of Resident 102's MDS, dated [DATE], the MDS indicated Resident 102 had clear speech, expressed ideas and wants, clearly understood verbal content, and had intact cognition.
The MDS indicated Resident 102 had ROM limitations in both arms and one leg.
The MDS indicated Resident 102 required substantial/maximal assistance for oral hygiene and upper body dressing and dependent for lower body dressing, rolling to both sides in bed, and moving from lying to sitting on the side of the bed.
During an interview on 6/26/2024 at 3:32 p.m. with the Director of Rehabilitation (DOR), Resident 102's Rehab Screening, dated 4/5/2024, was reviewed.
The DOR stated PT 1 should have reported Resident 102's decline to nursing as a change in condition.
The DOR stated Resident 102 did not receive any PT or OT services after the Rehab Screening, dated 4/5/2024.
During an interview on 6/28/2024 at 11:22 a.m. with the Director of Nursing (DON), the DON stated changes in condition need to be reported to nursing to assess the resident thoroughly and to notify the physician for intervention.
During a review of the facility's policy and procedure (P&P) titled, Change in Condition: Notification of, dated effective on 8/25/2021, the P&P indicated the facility must immediately inform the resident and consult with the resident's physician where there was a significant change in the resident's physical status and a need to alter treatment.
Cross Reference F-F688
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was admitted to the facility on [DATE] with diagnoses including acute pyelonephritis (a bacterial infection causing inflammation of kidneys), benign prostatic hyperplasia (non-cancerous enlargement of prostate gland), and hemiplegia (paralysis of one side of the body) following cerebral infarction (damage to the brain from interruption of its blood supply) During a review of Resident 105's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 5/28/2024, the MDS indicated Resident 105 had an intact cognition (ability to think, understand, learn, and remember) and required partial assistance with transfer to and from bed to chair, toilet transfer, toileting hygiene and dressing.
During a Resident Council Meeting on 6/25/2024, at 11:15 a.m., Resident 105 stated he did not know how to file a grievance or who was the person to approach if he needed assistance or help to file a grievance or address a concern.
During an interview on 5/27/2024, at 5:31 p.m. with the Social Service Director (SSD), SSD stated the resident filled up a form if they had grievance about their care or missing personal items, refer them to the appropriate department and present their findings to the residents once they had reached a conclusion and resolution. SSD stated it was important for residents to know how to file grievance so the facility can address their needs and concerns.
During an interview on 6/28/2024, at 6:22 p.m., with the Director of Nursing (DON), the DON stated residents should know how to file a grievance so the facility can meet their needs and prevent frustration among residents who required assistance in filing a grievance.
During a review of facility's policy and procedure (P&P) titled Grievance/ Concern dated 8/25/2021, the P&P indicated Information about grievance will be provided upon admission or upon request, the resident or resident representative are provided with the Grievance Policy which informs of their right to voice grievances or concerns and the process for doing so.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
elimination.
Documentation regarding the use of restraints shall include full documentation of the
range of motion and repositioning flow sheets.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During an interview and record review of facility's Policy and Procedure about Background Screening Investigations with DON and ADM on 6/28/2024, at 9:59 p.m. DON read and validated the policy if background investigation discloses any misrepresentation on the application or former information indicating the individual has been convicted of abuse, neglect, mistreatment of individuals should not be employed. ADM and DON stated they did not read the letter or documents from California Board of Nursing regarding RNS 1's prior administrative disciplinary actions. ADM stated the background check of RNS 1 was clear and the facility was an equal opportunity and they do not discriminate and give everyone a chance to be hired in the facility.
During a review of facility's policy and procedure (P&P) titled Background Screening Investigation revised 2008, the P&P indicated the facility conducts employment background screening checks, reference checks, and criminal conviction checks on all applicants for positions with direct access to residents.
The P&P indicated licensed professional applying for a position that involve direct contact with residents their respective licensing board should be contacted to determine if any sanctions(a threatened penalty for disobeying a law or rule) have been assessed against the applicant's license.
The P&P indicated should the background investigation disclose any misrepresentation on the application form or information indicating the individual has been convicted of abuse, neglect, mistreatment of individuals the applicant should not be employed or contracted.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 had moderately impaired cognition and required substantial/maximal assistance for upper body dressing, lower body dressing, rolling from side to side in bed, chair/bed-to-chair transfers, and walking 10 feet.
The MDS indicated Resident 57 did not have any ROM impairment to both arms and had ROM impairments in one leg.
During an observation on 6/24/2024 at 1:25 p.m. in the hallway, Resident 57 was sitting in the wheelchair wearing a left-hand WHFO.
During a concurrent interview and record review on 6/26/2024 at 5:23 p.m. with the MDS Coordinator (MDSC), Resident 57's Rehab Screening, dated 3/21/2024, and MDS, dated [DATE], were reviewed.
The MDSC stated Resident 57's Rehab Screen indicated Resident 57 had ROM impairments in the left arm.
The MDSC stated Resident 57's MDS, dated [DATE], was inaccurate and should have indicated Resident 57 had a ROM impairment in one arm and did not have any ROM impairments in both legs.
The MDSC stated the MDS was a representation of the resident's abilities and the information on the MDS was sent to the federal database.
The MDSC stated inaccurate information was sent to the federal database for Resident 57's MDS, dated [DATE].
During a review of Resident 11's Minimum Data Set (MDS-standardized assessment and care screening tool) dated 03/26/2024 indicated Resident 11 had severe cognitive impairment (ability to learn, understand, and make decisions) and dependent on all activities of daily living.
During a review of Resident 15's admission Order, the admission Record indicated Resident 15 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including dysphagia, bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows) and paranoid schizophrenia (a severe mental health condition).
During a review of Resident 15's MDS dated [DATE] indicated Resident 15 had severe cognitive impairment and requires dependent assistance for all activities of daily living.
During a review of Resident 57's admission Order, the admission Record indicated Resident 57 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses of congestive heart failure (occurs when either disease or defect causes the heart muscle to lose the ability to pump blood efficiently) , dysphagia, and ischemic cardiomyopathy (refers to the heart's decreased ability to pump blood properly, due to myocardial damage brought upon by ischemia).
During a review of Resident 57's MDS dated [DATE] indicated Resident 57 had moderate cognitive impairment and requires dependent assistance for oral hygiene, toileting hygiene, shower/bath self and putting on/taking off footwear and maximum assistance for upper/lower body dressing and personal hygiene.
During an interview on 06/27/2024 at 10:39 a.m., the Director of Nursing (DON) stated residents who are PASRR I positive needs PASARR II evaluation.
The DON stated residents taking combinations of psychotropic medications needs to be re-evaluated to find out when those behavioral symptoms started and the reason why residents are taking those combinations of psychotropic medications and evaluate if it was really working and managing the symptoms.
During the review of facility's policy and procedure (P&P) titled Psychotropic Medication Use undated, indicated: This Policy sets forth procedures relating to psychotropic medication use.
Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During an interview on 6/25/2024 at 4:22 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 102 sometimes cries due to the left knee pain.
During an interview and record review on 6/27/2024 at 9:48 a.m. with Registered Nurse Supervisor 1 (RNS 1), Resident 102's physician order, dated 6/25/2024, for the Orthopedic consultation was reviewed. RNS 1 stated she assessed Resident 102, including the left knee contracture, on 6/25/2024. RNS 1 stated Resident 102 started to cry while thanking RNS 1 for calling the physician for the orthopedic specialist consultation because Resident 102 felt frustrated about the left knee.
RNS 1 stated Resident 102's physician provided orders for an orthopedic consultation and a physiatrist (medical doctor who specializes in physical medicine and rehabilitation) consultation on 6/25/2024.
During an interview on 6/27/2024 at 11:48 a.m. with the Physiatrist (MD 1), MD 1 stated Resident 102 wanted to walk again and made a recommendation for a referral to an orthopedic surgeon for the left knee. MD 1 stated he had previously recommended a referral to an orthopedic surgeon and informed social work of the recommendation.
During an interview on 6/27/2024 at 4:08 p.m. with the Social Service Assistant (SSA), SSA stated nursing was supposed to schedule the orthopedic specialist appointment and then the social services department will arrange transportation for the appointment.
During an interview on 6/27/2024 at 5:09 p.m. with the Director of Social Services (DSS) and the Director of Nursing (DON), the DSS was not aware of Resident 102's physician order for an Orthopedic specialist appointment. DSS stated the nurse receiving the physician's order for the Orthopedic specialist was supposed to make the appointment. DSS stated social services will then arrange transportation for the appointment.
During an interview on 6/27/2024 at 5:10 p.m. with the DON, the DON stated Resident 102's biggest concern was the left knee and RNS 1 should have made the orthopedic specialist appointment.
During an interview on 6/28/2024 at 8:43 a.m. with RNS 1, RNS 1 stated Resident 102's physician orders for the Orthopedic consultation should have been printed out and provided to social services for additional guidance. RNS 1 stated she will contact three Orthopedic specialist offices on 6/27/2024 to make an appointment for Resident 102.
During a review of the facility's policy and procedure (P&P) titled, Physician Orders, effective on 3/22/2022, the P&P indicated the Licensed Nurse receiving the order will be responsible for documenting and implementing the order.
During a review of the facility's P&P titled, Referrals, Social Services, revised 12/2008, the P&P indicated social services will collaborate with nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.
Cross reference F-F697.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During an interview on 6/27/2024 at 1:42 p.m. a Certified Nursing Assistant (CNA 5) in Resident 61's room, CNA 5 stated Resident 61 was dressed in a hospital gown because Resident 61 had pain in the left arm, preventing Resident 61 from putting on a shirt. CNA 5 stated Resident 61 did not like to get out of bed because Resident 61 felt pain throughout the body. Resident 61 stated the left arm pain prevented Resident 61 from getting dressed and getting out of bed.
During a concurrent interview and record review on 6/27/2024 at 5:16 p.m. with the DON and DOR, Resident 61's Census List, OT Evaluation, dated 3/22/2019, Rehab Screening, dated 2/2/2022 and 5/2/2022, Documentation Survey Report for RNA for 2/2022, 3/2022, 4/2022, 5/2022, and 6/2022, and OT Evaluation, dated 6/12/2022, were reviewed.
The DON and DOR reviewed Resident 61's Census List and stated Resident 61 never left the facility after admission on [DATE].
The DON and DOR reviewed Resident 61's OT Evaluation, dated 3/22/2019, which indicated Resident 61's ROM in the right arm was WFL but had impaired ROM in Resident 61's left shoulder, left elbow into extension but could bend completely, and left ring finger and small finger.
The DON and DOR reviewed Resident 61's Rehab Screening, dated 2/2/2022.
The DON stated the Rehab Screening, dated 2/2/2022, indicated the ROM in Resident 61's left arm and left leg were impaired but did not indicate which joints were impaired and the severity of the impairments.
The DON stated Resident 61's Rehab Screening, dated 2/2/2022, indicated Resident 61 wanted an RNA program for ROM to both arms and both legs.
The DON and DOR reviewed Resident 61's Documentation Survey Report for RNA from 2/2022 to 5/2022.
The DOR stated Resident 61 did not receive PROM to the left arm from 2/2022 to 5/2022.
The DOR and DON reviewed Resident 61's Rehab Screen, dated 5/2/2022.
The DON stated the Rehab Screening, dated 5/2/2022, indicated the ROM in Resident 61's left arm and left leg were impaired but did not indicate which joints were impaired and the severity of the impairmen[TRUNCATED]
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
residents By providing a system to identify, assess, treat, and evaluate pain.
The P&P also indicated
change in condition or change in pain status.
Cross reference F-F684 and F-F755.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During an interview on 6/25/2024 at 4:22 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 102 sometimes cried due to the left knee pain.
During a concurrent interview and record review on 6/27/2024 at 11:03 a.m. with the Director of Nursing (DON), Resident 102's physician orders for lidocaine cream to the right shoulder, dated 1/9/2024, and the MAR for 4/2024 and 5/2024 were reviewed.
The DON stated Resident 102's physician orders for the lidocaine cream indicated to apply the cream to Resident 102's right shoulder.
The DON reviewed Resident 102's MAR for 4/2024 and 5/2024 and stated the licensed nurses were applying the lidocaine cream to Resident 102's left knee to address Resident 102's left knee pain.
The DON stated the licensed nurses were not applying the lidocaine cream to the right shoulder in accordance with Resident 102's physician orders.
During a review of the facility's policy and procedure (P&P) titled, Mediation Administration - General Guidelines, the P&P indicated medications were administered in accordance with written orders of the attending physician.
Cross reference F-F697.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a review of facility's policy and procedure (P&P) untitled and undated, indicated the Policy sets forth procedures relating to psychotropic medication use.
For prn psychotropic medications should be ordered for no more than 14 days and each resident who was taking a prn psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a review of the facility's P&P titled, Medication Orders, dated 4/2008, the P&P indicated, the prescriber is contacted for direction when the medication will not be available.
Cross Reference F-F755
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During an interview on 6/26/2024 at 3:16 p.m. with LVN 4 stated Humulin R for Resident 107 should have an open date to determine expiration date after being removed from the refrigerator. LVN 4 stated the vial was almost full and he did not use much insulin from that vial.
During a concurrent interview on 6/26/2024 at 3:35 p.m. with LVN 4 and LVN 5, LVN 5 stated gabapentin should be stored in refrigerator according to manufacturer and pharmacy label on the bottle but did not know what to do after removing from refrigerator.
During an interview on 6/26/2024 at 4:43 p.m. with LVN 4, LVN 4 stated gabapentin was placed in medication cart by the nighttime nurse. LVN 4 stated gabapentin should be stored in the refrigerator otherwise the medication may lose its effectiveness and safety. LVN 4 stated Resident 22 would be at increased risk for seizures, injury, and hospitalization if medication was not effective for the resident. LVN 4 stated Resident 104 was prescribed gabapentin for seizures ( sudden, uncontrolled burst of electrical activity in the brain ) and pain. LVN 4 stated due to improper storage of gabapentin, there was a risk that Resident 104 would get agitated if not adequately treated for pain and would also be at risk for seizures and hospitalization. LVN 4 stated Humulin R for Resident 107 should have an opened date after removing from the refrigerator. LVN 4 stated Humulin R would not be safe or effective to treat high blood sugar, which would increase the risk for hospitalization or even death for Resident 107 due to the insulin not being stored according to manufacturer's requirements.
During an interview on 6/27/2024 at 9:34 a.m. with the registered pharmacist (RPH) 1 at pharmacy (PH), RPH 1 stated the pharmacy provided gabapentin solution to the facility for Resident 22 and Resident 104. RPH 1 stated both gabapentin solutions were supplied in manufacturer bottle, not an extemporaneous preparation. RPH 1 stated gabapentin solution bottles for Residents 22 and 104 were required to be stored in refrigerator at 2°C-8°C (36°F to 46°F). RPH 1 stated gabapentin solution for Resident 22 was filled on 6/15/2024, and gabapentin solution for Resident 104 was filled on 6/24/2024 or 6/25/2024.
During an interview on 6/27/2024 3:05 p.m. with the DON, the DON stated gabapentin should be stored in refrigerator to maintain safety and effectiveness. DON stated Resident 22 and Resident 104 would be at high risk for seizures and hospitalization if the condition was not well controlled with gabapentin that was inappropriately stored. DON stated Humulin R insulin should be stored in refrigerator and labeled with an open date once removed from the refrigerator. DON stated Resident 107's blood sugar would not be well controlled, and resident would be at risk for hospitalization if the insulin was not effective due to inappropriate storage conditions.
During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 04/2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.
Medications requiring refrigeration or temperatures between 2°C (36°F) and 8°C (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring.
Outdated, contaminated, or deteriorated medications are immediately removed from stock, disposed of according to procedures for medication disposal.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a concurrent kitchen observation and interview with the Dietary Supervisor (DS) on 6/27/2024 at 12:06 p.m., observed snacks/nourishment stored in the refrigerator were not labeled with preparation date or expiration date. DS stated the snacks were just prepared and stored in the refrigerator to cool down for lunch service.
The DS stated it was not labeled with the date of preparation.
During a review of facility's policy and procedure (P&P) titled, Food receiving and storage, (undated) the P&P indicated all foods stored in the refrigerator or freezer must be covered labelled and dated.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a review of the QAPI plan received, the active QAPI plan included falls, wounds, and weights.
During a concurrent interview and record review of the QAPI plan on 6/28/2024 at 6:50 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the QAPI plan for weight variance and wound management was initiated.
The ADON stated cannot provide documented evidence QAPI plan was being implemented.
The ADON also indicated they wish they had a map they can use to compare the different months for the weight variance.
During a concurrent interview and record review of QAPI plan on 6/28/2024 at 8:54p.m. with the DON, the DON stated the facility had initiated a QAPI plan for weight variance in May 2024.
The DON stated the plan was to look at the interventions in place if the intervention was not working for the first month, they will change the plan and have more huddles.
The DON stated the facility cannot provide documented evidence they implemented this plan.
The DON stated they have a process in place but does not have a list of how many residents had weight variance.
The DON could not provide documented evidence of the implementation or evaluation of QAPI plan for weight variance, falls or wound management.
During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership, revised March 2020, the P&P indicated the responsibilities of the QAPI Committee were to collect and analyze performance indicator data and other information, identify, evaluate, monitor, and improve facility systems and processes that support the delivery of care and services.
The P&P indicated the facility has the full authority to oversee the implementation of the QAPI Program, including appropriately interpreting data within the context of standards of care, benchmarks, targets and the strengths and challenges of the facility.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a review of Resident 80's admission Record dated 6/25/2024, the admission Record indicated Resident 80 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a medical condition with high blood sugar) with diabetic neuropathy (a medical condition with nerve pain), elevated (increased) white blood cell (blood cells that help body fight infections and diseases) count, dermatitis (a condition described as irritation and swelling of skin) and urinary tract (a medical term used to describe drainage system for removing urine) infection.
During an observation on 6/25/2024 at 9:00 a.m. in Resident 80's room during medication administration, Licensed Vocational Nurse (LVN) 2 placed the medication tray next to resident's urinal (a receptacle typically used by bedridden men to urinate) on the bedside table.
There was an empty urinal placed horizontally and a urinal with yellow colored liquid placed vertically on the bedside table.
LVN 2 proceeded to administer twelve medications to Resident 80.
During an interview on 6/25/2024 at 2:20 p.m. with LVN 2, LVN 2 stated Resident 80 was made aware about the urinal to be placed at the bedside with the holder, but the resident argued and wanted both urinals on the table. LVN 2 stated Resident 80 was really set in his own ways and did not understand the risk of infection if urinal was placed near personal belongings and medications. LVN 2 stated this was also a dignity issue and facility policy indicated urinal should be in a container.
During an interview on 6/26/2024 2:06 p.m. with the Director of Nurses (DON), the DON stated urinals should be hung with the dignity bag next to the bed where resident can grab comfortably depending on their limitations.
The DON stated there would be a risk of cross-contamination, infection and hospitalization for facility staff and residents. DON stated, licensed staff should have cleaned the bedside table, drained the urine, then give the meds and inform resident if she can administer medications first and then bring the urinal.
The DON stated Resident 80 did not understand this precautionary measure, so she would continue to educate the resident about the risks of having medications next to open urinal on the bedside table.
During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 09/18/2023, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and . to help prevent the development and transmission of communicable diseases and infections.
Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures; communicating the importance of standard precautions.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a concurrent interview on 6/27/2024 at 9:19 a.m., with the Infection Preventionist (IP), the IP stated the facility used Mcgeers criteria (infection surveillance guidance) before resident will start on antibiotic treatment and it was a requirement to make sure the facility was compliant with the standard practice. IP stated that at least three criteria are present before resident can start on antibiotic treatment.
During a concurrent interview and record review on 06/27/2024 at 3:01 p.m., with IP, RR indicated there was no documentation in all three residents (Resident 12, 47, and 111) meeting the criteria that all three residents need to take antibiotic treatment. IP stated that if resident was taking antibiotic and was not necessary then it puts the resident at high risk to developing resistant to the medication.
During a review of the facility's policy and procedure titled, Antibiotic Stewardship dated 09/18/2023 indicated Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program.
The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.
When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
assessments of pneumococcal vaccination status are conducted within five days of the resident's
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
vaccination status and vaccine administration record is provided to the individual with a copy filed in
its residents which includes:
a. staff name b. initial start of employment c.
Termination of employment d. job title or role e. assigned work area f. a brief description of how they interact with residents. g. vaccination status
- specific vaccine received
- dates of each dose
- dates of the next scheduled dose
- any booster doses, exemption status, delays.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a concurrent observation and interview on 6/24/2024 at 9:00 a.m. with Occupational Therapist 1 (OT 1 profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) in the therapy gym, a grey-colored adjustable height therapy mat was located against the wall next to the door.
The therapy mat appeared slanted with one side of the mat, closet to the door, lower than the opposite site of the mat. OT 1 raised the height of the mat using a remote and stated the therapy mat continued to have a slanted position. OT 1 stated residents used the therapy mat at the lowest position.
During a concurrent observation and interview on 6/25/2024 at 1:50 p.m. with the Director of Rehabilitation (DOR) in the therapy gym, the DOR stated the adjustable height therapy mat was replaced with another therapy mat today.
The DOR stated an outside company inspected the equipment on 11/2023 and did not know the reason the adjustable height therapy mat was not replaced at that time.
During an interview on 6/26/2024 at 10:00 a.m. with the DOR, the DOR stated the adjustable height therapy mat was replaced because the surface was uneven, which could potentially cause injury or falls to the residents.
During an interview on 6/28/2024 at 10:58 a.m. with the Maintenance Supervisor (MS), the MS stated an outside company inspected the therapy gym and equipment but did not routinely check the therapy mat and equipment.
During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 12/2009, the P&P indicated the Maintenance Department was responsible for maintain the building, grounds, and equipment in a safe and operable manner at all times.
The P&P also indicated the maintenance staff provided routine maintenance service to all areas.
055995 06/28/2024
North Long Beach Post Acute 260 E Market St Long Beach, CA 90805
During a Resident Council Meeting on 6/25/2024, at 11:15 a.m., Resident 105 stated he did not know how to file a grievance or who was the person to approach if he needed assistance or help to file a grievance or address a concern.
During an interview on 5/27/2024, at 5:31 p.m. with the Social Service Director (SSD), SSD stated the resident filled up a form if they had grievance about their care or missing personal items, refer them to the appropriate department and present their findings to the residents once they had reached a conclusion and resolution. SSD stated it was important for residents to know how to file grievance so the facility can address their needs and concerns.
During an interview on 6/28/2024, at 6:22 p.m., with the Director of Nursing (DON), the DON stated residents should know how to file a grievance so the facility can meet their needs and prevent frustration among residents who required assistance in filing a grievance.
During a review of facility's policy and procedure (P&P) titled Grievance/ Concern dated 8/25/2021, the P&P indicated Information about grievance will be provided upon admission or upon request, the resident or resident representative are provided with the Grievance Policy which informs of their right to voice grievances or concerns and the process for doing so.
055995
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 055995 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Convalescent Center of North Long Beach 260 E Market St Long Beach, CA 90805
During a review of Resident 60's Admission Record, dated 6/25/2024, indicated, Resident 60 was admitted to the facility on [DATE] with diagnosis including dry eye syndrome of bilateral (a term used to describe two sides) lacrimal glands (a term used for tear glands that supplies tear fluid in the eyes).
During a review of Resident 60's History and Physical (H&P), dated 6/3/2024, indicated patient could not make decisions but could make needs known.
During a review of Resident 60's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 5/22/2024, the MDS indicated Resident 60 had intact cognition (ability to think, understand, learn, and remember) and required moderate to complete assistance from facility staff for activities of daily living (tasks of everyday life that include personal hygiene, dressing, getting in and out of bed or chair, bathing, and toileting).
During a review of Resident 60's Physician Order Summary Report, dated 6/25/2024, the order summary report indicated the following medication:
Restasis Ophthalmic (a term used for eyes) emulsion (a mixture of two or more liquids that do not form uniform composition) 0.05 percent (% - a term used to indicate concentration) (Cyclosporine) instill one drop to both eyes two times a day for dry eye syndrome order date: 9/18/2023, start date: 9/19/2023.
055995
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 055995 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Convalescent Center of North Long Beach 260 E Market St Long Beach, CA 90805
During a concurrent observation and interview on 6/25/2024 at 4:04 p.m. with Assistant Director of Nursing (ADON) in the Medication Room Station 1, the following medications and/or dietary supplements were found to be expired:
1a.
Four unopened bottles of cranberry 450 milligrams (mg - a unit of measurement) tablets; expiration date: 05/2024
1b.
One unopened bottle of simethicone 80 mg chewable tablets; expiration date: 03/2024
1c.
Four unopened bottles of calcium 600 mg plus vitamin D 5 micrograms (mcg - a unit of measurement) or 200 international units (IU - a unit of measurement) tablets; expiration date: 04/2024
1d.
Two unopened bottles of vitamin B12 500 mcg tablets; expiration date: 03/2024
1e.
One unopened bottle of vitamin B12 1000 mcg tablets; expiration date: 02/2024
1f.
One unopened bottle of bisacodyl 5 mg tablets, expiration date: 04/2024
055995
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 055995 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Convalescent Center of North Long Beach 260 E Market St Long Beach, CA 90805
During a review of Resident 102's Admission Record, indicated the facility admitted Resident 102 on 1/9/2024 with diagnoses including pain in the right elbow, psychosis (severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality), and depression.
During a review of Resident 102's Physician Orders, dated 1/9/2024, indicated to apply lidocaine external cream to the right shoulder topically one time a day for shoulder pain.
055995
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 055995 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Convalescent Center of North Long Beach 260 E Market St Long Beach, CA 90805
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.