Health inspection·June 7, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone). This deficient practice resulted in the inability of CDPH to investigate Resident 1 ' s injury of femur fracture in a timely manner and had the potential for facts related to the injury to be forgotten by staff. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (damage or disease that affects the brain leading to the person to be confused), dementia (a condition of loss of cognitive functioning such as thinking, remembering, and reasoning that it interferes with a person ' s daily life and activities) and generalized weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/31/2024, the MDS indicated Resident 1 was not able to make decisions that were consistent and reasonable. During a review of Resident 1 ' s SBAR dated 5/20/2023 and timed at 10:38 a.m., the SBAR indicated Resident 1 was groaning and screaming while facility staff assisted her with lower body dressing (pulling Resident 1 ' s pants up). The SBAR indicated Resident 1 was noted with swelling to her right knee, Resident 1 ' s physician was informed and an order for a Stat (immediate) right knee X-ray was obtained. During a review of Resident 1 ' s X-ray report dated 5/20/2024, the X-ray report indicated Resident 1 sustained a moderately displaced fracture of the distal diaphysis of the femur of indeterminate age with moderate degenerative change of the knee with narrowing of the lateral joint compartment (the area on the outside portion of the knee joint). During a review of Resident 1 ' s Transfer Form dated 5/20/2024 at 5:05 p.m., the Transfer Form indicated Resident 1 was transferred to General Acute Care Hospital (GACH) for evaluation and treatment due to her femur fracture. Page 1 of 4 055531 055531 06/07/2024 Beachside Post Acute 22520 Maple Avenue Torrance, CA 90505

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/7/2024 at 11:55 a.m., the Director of Nursing Services (DON) stated Resident 1 was transferred to the GACH because she (Resident 1) sustained a fracture to her right femur. The DON stated she did not report this injury to CDPH because Resident 1 ' s physician documented Resident 1 ' s fracture was unavoidable due to Resident 1 ' s diagnoses of osteoporosis (brittle bones). During an interview on 6/7/2024 at 12:55 p.m., the Administrator (ADM) stated the facility should have reported to CDPH when Resident 1 sustained an injury of an unknown. During a review of the facility ' s policy and procedure (P/P), titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised 4/2021, the P/P indicated if an injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to the State law. The Administrator or the individual making the allegation immediately reports his or her suspicion to the State licensing/certification agency responsible for surveying/licensing the facility within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 055531 Page 2 of 4 055531 06/07/2024 Beachside Post Acute 22520 Maple Avenue Torrance, CA 90505

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to ensure an injury of unknown origin was investigated for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone) and the cause of the fracture was unknown to the resident and staff. Residents Affected - Few This deficient practice resulted in the inability of the facility to determine what might have been the cause of Resident 1 ' s injury and had the potential to recur. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (damage or disease that affects the brain leading to the person to be confused), dementia (a condition of loss of cognitive functioning such as thinking, remembering, and reasoning that it interferes with a person ' s daily life and activities) and generalized weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/31/2024, the MDS indicated Resident 1 was not able to make decisions that were consistent and reasonable. During a review of Resident 1 ' s SBAR dated 5/20/2023 and timed at 10:38 a.m., the SBAR indicated Resident 1 was groaning and screaming while facility staff assisted her with lower body dressing (pulling Resident 1 ' s pants up). The SBAR indicated Resident 1 was noted with swelling to her right knee, Resident 1 ' s physician was informed and an order for a Stat (immediate) right knee X-ray was obtained. During a review of Resident 1 ' s X-ray report dated 5/20/2024, the X-ray report indicated Resident 1 sustained a moderately displaced fracture of the distal diaphysis of the femur of indeterminate age with moderate degenerative change of the knee with narrowing of the lateral joint compartment (the area on the outside portion of the knee joint). During a review of Resident 1 ' s Transfer Form dated 5/20/2024 at 5:05 p.m., the Transfer Form indicated Resident 1 was transferred to General Acute Care Hospital (GACH) for evaluation and treatment due to her femur fracture. During an interview on 6/7/2024 at 11:55 a.m., the Director of Nursing Services (DON) stated she did not investigate Resident 1 ' s injury of unknown origin because, per Resident 1 ' s physician it was unavoidable due to Resident 1 ' s diagnosis of osteoporosis (brittle bones). During an interview on 6/7/2024 at 12:55 p.m., the Administrator (ADM) stated the facility should have investigated Resident 1 ' s fracture to determine the root cause of Resident 1 ' s injury. During a review of the facility ' s Policy and Procedure (P/P), titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 4/2021, the P/P indicated all reports of resident abuse, including injuries of unknown origin, are thoroughly investigated by facility 055531 Page 3 of 4 055531 06/07/2024 Beachside Post Acute 22520 Maple Avenue Torrance, CA 90505

F 0610 management. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055531 Page 4 of 4