Shoreline Healthcare Center

F-F609)

Findings:

During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE REDACTED] with diagnoses including confirmed physical abuse, major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety disorder.

During a review of Resident 2's History and Physical (H&P) dated 3/15/2025, the H&P indicated Resident 2 was admitted to the facility from a general acute care hospital (GACH) due to adult physical abuse causing traumatic ecchymosis (bruising). The H&P indicated Adult Protective Services (APS - a government agency that investigates allegations of a vulnerable adult being or having been abused, neglected, or exploited by their caregivers), and the police had been notified of the abuse by the GACH. The H&P indicated it was unclear if Resident 2 was able to make her own medical decisions and she was making medical decisions with the help of her sister (FM 5). The H&P indicated do not give any information to FM 4, in the plan of treatment.

During a review of Resident 2's care plan titled, At risk for re-traumatization related to (r/t) history of physical abuse by a close family member initiated on 3/18/2025, the Care Plan goals included Resident 2 would have no evidence of emotional, physical, and psychological problems. The Care Plan interventions included encouraging Resident 2 to attend care conferences, to express preferences and participate in the care planning process.

During a review of Resident 2's Interdisciplinary Team (IDT, brings together knowledge from different health care disciplines to help people receive the care they need)- Care Plan Review dated 3/18/2025, the IDT Care Plan Review indicated Resident 2 had an APS case against FM 4 for physical abuse. The IDT Care Plan

Review indicated Resident 2 expressed that she did not want any calls or visits from FM 4. Resident 2 also expressed she felt threatened by FM 4, and FM 4 should also be banned from calling or visiting her. Resident 2 expressed she did not want to be discharged home with FM 4 because of the abuse. The IDT documentation indicated FM 4 was verbally, emotionally, financially, and physically abusive towards Resident 2 for years and multiple police reports were filed but Resident 2 always took FM 4 back in until the last event (date no specified) that led to her most recent hospitalization and she decided to press charges against FM 4 and not return to their apartment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 055353 Department of Health & Human Services Printed: 08/28/2025 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 055353 B. Wing 04/18/2025

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

Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

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 0610 During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 3/21/2025, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and Level of Harm - Minimal harm or understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 2 was potential for actual harm not receiving any medications for anxiety.

Residents Affected - Few During a review of Resident 2's Case Manager (CM) Progress Notes dated 3/18/2025, the Case Manager Progress Notes indicated the CM was notified FM 4 was at the facility to visit Resident 2. The CM Progress Notes indicated the CM had been notified by Resident 2 that she did not want visits from FM 4. The CM Progress Notes indicated the CM notified FM 4 of Resident 2's wishes, and FM 4 proceeded to walk towards Resident 2's room stating, that is a lie! I was just there yesterday, and I took a train and two buses to get here. The CM Progress Notes indicated the CM asked FM 4 to wait in the lobby so she (CM) could confirm Resident 2's wishes, and Resident 2 again stated she did not want any calls or visits from FM 4. The CM Progress Notes indicated the CM relayed the message to FM 4, and he became agitated using profanity (bad words). The CM Progress Notes indicated the Police had to be called before FM 4 agreed to leave the facility. The CM Progress Notes indicated Resident 2's chart was updated, and staffing was made aware of Resident 2's wishes to not have visits from FM 4.

During a review of Resident 2's Social Services Summary Note dated 3/21/2025, the Social Services Summary Note indicated Resident 2 was verbally responsive with capacity to understand and make decisions. The Social Services Summary Note indicated Resident 2 was unable to sleep well, had anxiety and worries about FM 4 who was physically abusive towards Resident 2.

During a review of Resident 2's CM Note dated 4/8/2025, the CM Note indicated after lunch (lunch was served by 12:30 p.m.) on 4/8/2025 the CM was notified FM 4 was outside of Resident 2's room. The CM reminded FM 4 of Resident 2's wishes, and he became hostile and aggressive pushing past the CM and two other staff (unknown) to enter Resident 2's room. The CM Note indicated Resident 2's privacy curtain was pulled around Resident 2's bed for privacy and FM 4 proceeded to try and pull back the curtain as nursing staff (Licensed Vocational Nurse [LVN]3) was holding it shut. FM 4 was shouting to Resident 2, It's me FM 4, stop saying you do not want to see me. I came here to see you, tell them it is okay for me to see you, tell them it is okay for me to be here. The CM Note indicated Resident 2 was physically shaking her head No and Resident 2 was visually upset and tearful as she kept her eyes closed and continued shaking her head No. The CM Note indicated staff (unknown) intervened to prevent further interaction with Resident 2 and the police were called. FM 4 was escorted out of the building by two male staff (unknown) as FM 4 was verbally cursing profanities.

During a review of Resident 2's Change in Condition (COC) evaluation dated 4/8/2025, the COC indicated Resident 2 was experiencing emotional distress. The COC indicated Resident 2 reported feeling anxious

after the visit from FM 4 and emotional support was provided. MD 3 was notified and ordered; 1. monitor Resident 2 for emotional distress and 2. Ativan oral tablet 0.5 milligrams (mg) by mouth every eight hours as needed for anxiety manifested by verbalization of anxiousness with mild tremors for three days. 3. Psych consultation related to depression and anxiety.

During a review of Resident 2's Care Plan titled Potential for psychosocial well-being problem related to family discord (disagreement, or difference in opinion) dated 4/8/2025, the Care Plan goals included for Resident 2 not having any further indications of psychosocial wellbeing problems. The Care Plan interventions included allowing Resident 2 time to answer questions and to verbalize feelings and fears, consultation with behavioral health, and when conflict arises removing Resident 2 to a calm, safe environment and allowing Resident 2 to vent and share her feelings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 055353 Department of Health & Human Services Printed: 08/28/2025 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 055353 B. Wing 04/18/2025

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

Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

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 0610 During a review of Resident 2's medication administration record (MAR), the MAR indicated Resident 2 was given Ativan 0.5 mg one time on 4/9/2025 for feeling anxious. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2's Medication Administration Note dated 4/9/2025, the Medication Administration Note indicated Resident 2 was visibly shaken and anxious. Resident 2 was requesting Residents Affected - Few anti-anxiety medications and Resident 2 was given Ativan 0.5 mg.

During a review of Resident 2's COC (Condition) Follow-up dated 4/9/2025, the COC Follow-Up indicated Resident 2 had increased anxiety due to FM 4 and Resident 2 was calmer after receiving the Ativan 0.5 mg.

During an observation and concurrent interview on 4/14/2025 at 9:50 a.m., Resident 2's name was displayed at the entrance of her door. Resident 2 stated her mind was always wandering, and did not work like it used to.

During an interview on 4/15/2025 at 3:17 p.m., Resident 2 declined to elaborate on how FM 4 abused her prior to her admission to the facility. Resident 2 stated she was scared just hearing FM 4's voice when he got into the facility and the situation was mentally exhausting, but she prayed for FM 4 every day and just wanted to move forward with her life. Resident 2 stated the facility provided her with a number to call for therapy, but

she had yet to set up an appointment.

During an interview on 4/17/2025 at 10:20 a.m., with the CM, the CM stated Resident 2 had come to their facility after a stay in the GACH from sustaining injuries due to being physically assaulted by FM 4. The CM stated Resident 2 had an open APS case against FM 4 prior to her admission to the facility. The CM stated Resident 2 had been dealing with the abuse for several years until she decided to cut ties with FM 4 when

she was admitted to the GACH. The CM stated FM 4 had snuck into the facility two times that they know of;

on 3/18/2025 and 4/8/2025. The CM stated Resident 2 became visibly shaken up just by the mention of FM 4 being in the vicinity of the facility. The CM stated the first instance FM 4 entered the facility on 3/18/2025, she (the CM) was alerted a male was in Resident 2's room being disruptive so she went to investigate and informed FM 4 he was not welcome at the facility, Resident 2 did not wish to see him, and the police were called. The CM stated the second time he came back to the facility on [DATE REDACTED], FM 4 was immediately spotted by staff, staff tried to stop him from entering Resident 2's room but he pushed his way into the room and was trying to pull the privacy curtain open, but LVN 3 was holding the privacy curtain shut. The CM stated Resident 2 was receiving peri care, and her privates were exposed while FM 4 was trying to pull the privacy curtain open. The CM stated FM 2's voice was very aggressive, very loud, caused a huge commotion and he was yelling to Resident 2, God dammit you know you want to see me, why are you telling them you do not want to see me! and Resident 2 was crying and very shaken up by the occurrence. The CM stated the way FM 4 was talking, acting, and the tone of voice he was using was verbally and emotionally abusive. The CM stated the abuse coordinator (administrator [ADM]) was aware of the situation that occurred on 4/8/2025.

The CM stated she brought it up during a morning meeting with department heads that in GACHs, victims of violence do not have their names outside of their rooms for patient safety and the CM thought it would be a good idea to implement but she does not know what the facility did with that information. The CM stated she believed FM 4 found out what room Resident 2 was in by looking for and finding her name posted outside of her doorway. The CM stated they offered assistance to call a behavioral health self-referral number to set up

an appointment for therapy, but the resident declined.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 055353 Department of Health & Human Services Printed: 08/28/2025 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 055353 B. Wing 04/18/2025

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

Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

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 0610 During an interview on 4/17/2025 at 10:54 a.m., with the Social Services Director (SSD), the SSD stated Resident 2 became upset at the mention of FM 4's name so they had to respect her and not ask any Level of Harm - Minimal harm or questions because Resident 2 did not want to talk about any of the details. potential for actual harm

During an interview on 4/17/2025 at 1:42 p.m., with LVN 3, LVN 3 stated on 4/8/2025 FM 4 bypassed all the Residents Affected - Few safety checks in the facility and snuck into the facility behind another resident's family member (unknown). LVN 3 stated she knew a Certified Nursing Assistant (CNA) (unknown) was providing peri care to Resident 2 at the time, so LVN 3 entered Resident 2's room to check on the resident before FM 4 abruptly made his way past the CM (who was at the doorway of Resident 2's room) and was trying to pull Resident 2's privacy curtain open. LVN 3 stated she was pleading with FM 4 to give Resident 2 some privacy and to let the staff get Resident 2 decent, but FM 4 was cussing at the staff, saying F (fuck), F the police and shouting at Resident 2 to let FM 4 in. LVN 3 stated FM 4 was shouting multiple things at Resident 2, but she couldn't exactly remember everything that was said. LVN 3 stated Resident 2 was visibly in fear, shaking, and traumatized. LVN 3 stated the interaction was verbal abuse and emotional abuse by the way he was talking to Resident 2 and the response Resident 2 had to the interaction. LVN 3 stated Resident 2 ended up needing Ativan because she was so shaken up. LVN 3 stated the abuse coordinator (ADM) was aware of the situation but was not sure if the incident was reported to necessary agencies other than the police because

the police were called.

During an interview on 4/18/2025 at 10:36 a.m., with the ADM, the ADM stated she was the abuse coordinator for the facility. The ADM stated the facility was informed an open APS case was filed against FM 4 for the abuse Resident 2 sustained. The ADM stated the police were called after the first incident 3/18/2025 and staff were notified not to let FM 4 in and to call the police if they saw him. The ADM stated the second incident on 4/8/2025 she was incorrectly informed after the incident had happened, that FM 4 did not enter Resident 2's room and staff were able to stop him from entering the room. The ADM stated from what

she learned about the 4/8/2025 incident FM 4 was aggressive towards staff and just stated he wanted to see Resident 2, so she did not believe it was abuse but rather family dynamics. The ADM stated the incident was not reported to the state agency and a thorough investigation was not done but if she knew FM 4 entered the room and the details of the interaction she may have done things differently. The ADM read the details in Resident 2's medical record including the CM notes and COC dated 4/8/2025. The ADM stated she was not aware FM 4 entered Resident 2's room, was shouting towards Resident 2, and Resident 2 was shaking her head no and crying. The ADM stated it was important staff members reported accurate descriptions of events because that determined the course of action she takes and if an incident needed to be reported to

the state agency. The ADM stated she unfortunately never spoke to Resident 2 herself regarding the situation. The ADM stated according to the facility's policy and procedure (P/P) titled Abuse: Prevention of and Prohibition Against definition of mental abuse, mental abuse included harassment. The ADM stated if there was an allegation of abuse, the incident needed to be thoroughly investigated and reported to the state agency right away. The ADM stated Resident 2 remained in the same room from the time of admission (3/16/2025) to the time of discharge (4/17/2025) and she could not find any evidence in Resident 2's chart

she was offered a room change after the first incident on 3/18/2025, and the second incident on 4/8/2025 of FM 4 forcing his way into Resident 2's room for her safety. The ADM stated after the second incident on 4/8/2025, she (ADM) became worried about Resident 2's safety so she had the CM reach out to Resident 2's insurance to request a transfer to another facility but Resident 2's insurance declined.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 055353 Department of Health & Human Services Printed: 08/28/2025 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 055353 B. Wing 04/18/2025

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

Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

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 0610 During a review of the facility's P/P titled Abuse: Prevention of and Prohibition Against revised 12/2023, the P/P indicated each resident had the right to be free of abuse. The P/P indicated abuse was the willful (the Level of Harm - Minimal harm or individual acted deliberately) infliction of injury, unreasonable confinement, intimidation, or punishment potential for actual harm resulting in physical harm, pain, or mental anguish. The P/P indicated the facility was to ensure the health and safety of each resident with regards to visitors, such as family members, friends, or other individuals Residents Affected - Few subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. The P/P indicated mental abuse included, but was not limited to humiliation, harassment, and threats of punishment or deprivation. The P/P indicated the facility was to protect the resident from further abuse by making room changes as needed. The P/P indicated allegations of abuse would be promptly and thoroughly investigated. The P/P indicated the investigation would include an interview with the resident, interviews of any witnesses, a review of the resident's record, interviews of other residents, and a review of

the circumstances surrounding the incident. The P/P indicated the results of the investigation were to be documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 055353

F-F610)

Findings:

During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE REDACTED] with diagnoses including confirmed physical abuse, major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety disorder.

During a review of Resident 2's History and Physical (H&P) dated 3/15/2025, the H&P indicated Resident 2 was admitted to the facility from a general acute care hospital (GACH) due to adult physical abuse causing traumatic ecchymosis (bruising). The H&P indicated Adult Protective Services (APS - a government agency that investigates allegations of a vulnerable adult being or having been abused, neglected, or exploited by their caregivers), and the police had been notified of the abuse by the GACH. The H&P indicated it was unclear if Resident 2 was able to make her own medical decisions and she was making medical decisions with the help of her sister (FM 5). The H&P indicated do not give any information to FM 4, in the plan of treatment.

During a review of Resident 2's care plan titled, At risk for re-traumatization related to (r/t) history of physical abuse by a close family member initiated on 3/18/2025, the Care Plan goals included Resident 2 would have no evidence of emotional, physical, and psychological problems. The Care Plan interventions included encouraging Resident 2 to attend care conferences, to express preferences and participate in the care planning process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 15 055353 Department of Health & Human Services Printed: 08/28/2025 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 055353 B. Wing 04/18/2025

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

Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

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 0609 During a review of Resident 2's Interdisciplinary Team (IDT, brings together knowledge from different health care disciplines to help people receive the care they need)- Care Plan Review dated 3/18/2025, the IDT Care Level of Harm - Minimal harm or Plan Review indicated Resident 2 had an APS case against FM 4 for physical abuse. The IDT Care Plan potential for actual harm Review indicated Resident 2 expressed that she did not want any calls or visits from FM 4. Resident 2 also expressed she felt threatened by FM 4, and FM 4 should also be banned from calling or visiting her. Residents Affected - Few Resident 2 expressed she did not want to be discharged home with FM 4 because of the abuse. The IDT documentation indicated FM 4 was verbally, emotionally, financially, and physically abusive towards Resident 2 for years and multiple police reports were filed but Resident 2 always took FM 4 back in until the last event (date no specified) that led to her most recent hospitalization and she decided to press charges against FM 4 and not return to their apartment.

During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 3/21/2025, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 2 was not receiving any medications for anxiety.

During a review of Resident 2's Case Manager (CM) Progress Notes dated 3/18/2025, the Case Manager Progress Notes indicated the CM was notified FM 4 was at the facility to visit Resident 2. The CM Progress Notes indicated the CM had been notified by Resident 2 that she did not want visits from FM 4. The CM Progress Notes indicated the CM notified FM 4 of Resident 2's wishes, and FM 4 proceeded to walk towards Resident 2's room stating, that is a lie! I was just there yesterday, and I took a train and two buses to get here. The CM Progress Notes indicated the CM asked FM 4 to wait in the lobby so she (CM) could confirm Resident 2's wishes, and Resident 2 again stated she did not want any calls or visits from FM 4. The CM Progress Notes indicated the CM relayed the message to FM 4, and he became agitated using profanity (bad words). The CM Progress Notes indicated the Police had to be called before FM 4 agreed to leave the facility. The CM Progress Notes indicated Resident 2's chart was updated, and staffing was made aware of Resident 2's wishes to not have visits from FM 4.

During a review of Resident 2's Social Services Summary Note dated 3/21/2025, the Social Services Summary Note indicated Resident 2 was verbally responsive with capacity to understand and make decisions. The Social Services Summary Note indicated Resident 2 was unable to sleep well, had anxiety and worries about FM 4 who was physically abusive towards her.

During a review of Resident 2's CM Note dated 4/8/2025, the CM Note indicated after lunch (lunch was served by 12:30 p.m.) on 4/8/2025 the CM was notified FM 4 was outside of Resident 2's room. The CM reminded FM 4 of Resident 2's wishes, and he became hostile and aggressive pushing past the CM and two other staff (unknown) to enter Resident 2's room. The CM Note indicated Resident 2's privacy curtain was pulled around Resident 2's bed for privacy and FM 4 proceeded to try and pull back the curtain as nursing staff (Licensed Vocational Nurse [LVN]3) was holding it shut. FM 4 was shouting to Resident 2, It's me FM 4, stop saying you do not want to see me. I came here to see you, tell them it is okay for me to see you, tell them it is okay for me to be here. The CM Note indicated Resident 2 was physically shaking her head No and Resident 2 was visually upset and tearful as she kept her eyes closed and continued shaking her head No. The CM Note indicated staff (unknown) intervened to prevent further interaction with Resident 2 and the police were called. FM 4 was escorted out of the building by two male staff (unknown) as FM 4 was verbally cursing profanities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 15 055353 Department of Health & Human Services Printed: 08/28/2025 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 055353 B. Wing 04/18/2025

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

Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

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 0609 During a review of Resident 2's Change in Condition (COC) evaluation dated 4/8/2025, the COC indicated Resident 2 was experiencing emotional distress. The COC indicated Resident 2 reported feeling anxious Level of Harm - Minimal harm or after the visit from FM 4 and emotional support was provided. MD 3 was notified and ordered; 1. monitor potential for actual harm Resident 2 for emotional distress and 2. Ativan oral tablet 0.5 milligrams (mg) by mouth every eight hours as needed for anxiety manifested by verbalization of anxiousness with mild tremors for three days. 3. Psych Residents Affected - Few consultation related to depression and anxiety.

During a review of Resident 2's Care Plan titled Potential for psychosocial well-being problem related to family discord (disagreement, or difference in opinion) dated 4/8/2025, the Care Plan goals included for Resident 2 not having any further indications of psychosocial wellbeing problems. The Care Plan interventions included allowing Resident 2 time to answer questions and to verbalize feelings and fears, consultation with behavioral health, and when conflict arises removing Resident 2 to a calm, safe environment and allowing Resident 2 to vent and share her feelings.

During a review of Resident 2's medication administration record (MAR), the MAR indicated Resident 2 was given Ativan 0.5 mg one time on 4/9/2025 for feeling anxious.

During a review of Resident 2's Medication Administration Note dated 4/9/2025, the Medication Administration Note indicated Resident 2 was visibly shaken and anxious. Resident 2 was requesting anti-anxiety medications and Resident 2 was given Ativan 0.5 mg.

During a review of Resident 2's COC (Condition) Follow-up dated 4/9/2025, the COC Follow-Up indicated Resident 2 had increased anxiety due to FM 4 and Resident 2 was calmer after receiving the Ativan 0.5 mg.

During an observation and concurrent interview on 4/14/2025 at 9:50 a.m., Resident 2's name was displayed at the entrance of her door. Resident 2 stated her mind was always wandering, and did not work like it used to.

During an interview on 4/15/2025 at 3:17 p.m., Resident 2 declined to elaborate on how FM 4 abused her prior to her admission to the facility. Resident 2 stated she was scared just hearing FM 4's voice when he got into the facility and the situation was mentally exhausting, but she prayed for FM 4 every day and just wanted to move forward with her life. Resident 2 stated the facility provided her with a number to call for therapy, but

she had yet to set up an appointment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 055353 Department of Health & Human Services Printed: 08/28/2025 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 055353 B. Wing 04/18/2025

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

Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

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 0609 During an interview on 4/17/2025 at 10:20 a.m., with the CM, the CM stated Resident 2 had come to their facility after a stay in the GACH from sustaining injuries due to being physically assaulted by FM 4. The CM Level of Harm - Minimal harm or stated Resident 2 had an open APS case against FM 4 prior to her admission to the facility. The CM stated potential for actual harm Resident 2 had been dealing with the abuse for several years until she decided to cut ties with FM 4 when

she was admitted to the GACH. The CM stated FM 4 had snuck into the facility two times that they know of; Residents Affected - Few on 3/18/2025 and 4/8/2025. The CM stated Resident 2 became visibly shaken up just by the mention of FM 4 being in the vicinity of the facility. The CM stated the first instance FM 4 entered the facility on 3/18/2025, she (the CM) was alerted a male was in Resident 2's room being disruptive so she went to investigate and informed FM 4 he was not welcome at the facility, Resident 2 did not wish to see him, and the police were called. The CM stated the second time he came back to the facility on [DATE REDACTED], FM 4 was immediately spotted by staff, staff tried to stop him from entering Resident 2's room but he pushed his way into the room and was trying to pull the privacy curtain open, but LVN 3 was holding the privacy curtain shut. The CM stated Resident 2 was receiving peri care, and her privates were exposed while FM 4 was trying to pull the privacy curtain open. The CM stated FM 2's voice was very aggressive, very loud, caused a huge commotion and he was yelling to Resident 2, God dammit you know you want to see me, why are you telling them you do not want to see me! and Resident 2 was crying and very shaken up by the occurrence. The CM stated the way FM 4 was talking, acting, and the tone of voice he was using was verbally and emotionally abusive. The CM stated the abuse coordinator (administrator [ADM]) was aware of the situation that occurred on 4/8/2025.

The CM stated she brought it up during a morning meeting with department heads that in GACHs, victims of violence do not have their names outside of their rooms for patient safety and the CM thought it would be a good idea to implement but she does not know what the facility did with that information. The CM stated she believed FM 4 found out what room Resident 2 was in by looking for and finding her name posted outside of her doorway. The CM stated they offered assistance to call a behavioral health self-referral number to set up

an appointment for therapy, but the resident declined.

During an interview on 4/17/2025 at 10:54 a.m., with the Social Services Director (SSD), the SSD stated Resident 2 became upset at the mention of FM 4's name so they had to respect her and not ask any questions because Resident 2 did not want to talk about any of the details.

During an interview on 4/17/2025 at 1:42 p.m., with LVN 3, LVN 3 stated on 4/8/2025 FM 4 bypassed all the safety checks in the facility and snuck into the facility behind another resident's family member (unknown). LVN 3 stated she knew a Certified Nursing Assistant (CNA) (unknown) was providing peri care to Resident 2 at the time, so LVN 3 entered Resident 2's room to check on the resident before FM 4 abruptly made his way past the CM (who was at the doorway of Resident 2's room) and was trying to pull Resident 2's privacy curtain open. LVN 3 stated she was pleading with FM 4 to give Resident 2 some privacy and to let the staff get Resident 2 decent, but FM 4 was cussing at the staff, saying F (fuck), F the police and shouting at Resident 2 to let FM 4 in. LVN 3 stated FM 4 was shouting multiple things at Resident 2, but she couldn't exactly remember everything that was said. LVN 3 stated Resident 2 was visibly in fear, shaking, and traumatized. LVN 3 stated the interaction was verbal abuse and emotional abuse by the way he was talking to Resident 2 and the response Resident 2 had to the interaction. LVN 3 stated Resident 2 ended up needing Ativan because she was so shaken up. LVN 3 stated the abuse coordinator (ADM) was aware of the situation but was not sure if the incident was reported to necessary agencies other than the police because

the police were called.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 055353 Department of Health & Human Services Printed: 08/28/2025 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 055353 B. Wing 04/18/2025

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

Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

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 0609 During an interview on 4/18/2025 at 10:36 a.m., with the ADM, the ADM stated she was the abuse coordinator for the facility. The ADM stated the facility was informed an open APS case was filed against FM Level of Harm - Minimal harm or 4 for the abuse Resident 2 sustained. The ADM stated the police were called after the first incident potential for actual harm 3/18/2025 and staff were notified not to let FM 4 in and to call the police if they saw him. The ADM stated the second incident on 4/8/2025 she was incorrectly informed after the incident had happened, that FM 4 did not Residents Affected - Few enter Resident 2's room and staff were able to stop him from entering the room. The ADM stated from what

she learned about the 4/8/2025 incident FM 4 was aggressive towards staff and just stated he wanted to see Resident 2, so she did not believe it was abuse but rather family dynamics. The ADM stated the incident was not reported to the state agency and a thorough investigation was not done but if she knew FM 4 entered the room and the details of the interaction she may have done things differently. The ADM read the details in Resident 2's medical record including the CM notes and COC dated 4/8/2025. The ADM stated she was not aware FM 4 entered Resident 2's room, was shouting towards Resident 2, and Resident 2 was shaking her head no and crying. The ADM stated it was important staff members reported accurate descriptions of events because that determined the course of action she takes and if an incident needed to be reported to

the state agency. The ADM stated she unfortunately never spoke to Resident 2 herself regarding the situation. The ADM stated according to the facility's policy and procedure (P/P) titled Abuse: Prevention of and Prohibition Against definition of mental abuse, mental abuse included harassment. The ADM stated if there was an allegation of abuse, the incident needed to be thoroughly investigated and reported to the state agency right away. The ADM stated Resident 2 remained in the same room from the time of admission (3/16/2025) to the time of discharge (4/17/2025) and she could not find any evidence in Resident 2's chart

she was offered a room change after the first incident on 3/18/2025, and the second incident on 4/8/2025 of FM 4 forcing his way into Resident 2's room for her safety. The ADM stated after the second incident on 4/8/2025, she (ADM) became worried about Resident 2's safety so she had the CM reach out to Resident 2's insurance to request a transfer to another facility but Resident 2's insurance declined.

During a review of the facility's P/P titled Abuse: Prevention of and Prohibition Against revised 12/2023, the P/P indicated each resident had the right to be free of abuse. The P/P indicated abuse was the willful (the individual acted deliberately) infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The P/P indicated the facility was to ensure the health and safety of each resident with regards to visitors, such as family members, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. The P/P indicated mental abuse included, but was not limited to humiliation, harassment, and threats of punishment or deprivation. The P/P indicated the facility was to protect the resident from further abuse by making room changes as needed. The P/P indicated allegations of abuse would be reported outside of the facility to appropriate State or Federal agencies in the applicable timeframes as per regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 055353 Department of Health & Human Services Printed: 08/28/2025 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 055353 B. Wing 04/18/2025

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

Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45891 potential for actual harm Based on interview and record review, the facility failed investigate an allegation of abuse as indicated in the Residents Affected - Few facility's policy and procedure (P/P) for one of six sampled residents (Resident 2).

As a result of this deficient practice Resident 2 had the potential to experience additional mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) from Resident 2's alleged abuser, family member (FM) 4 causing Resident 2 increased anxiety (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities).

(cross reference