Health inspection·May 19, 2025

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. Based on interview and record review, the facility failed to implement its abuse prevention policy when they did not report an unusual occurrence of an acute new distal femur fracture (a break in the lower part of the thighbone, near the knee joint) of unknown cause to the State Survey Agency (California Department of Public Health - CDPH) within 24 hours of the occurrence, for one of the three sampled residents (Resident 1). This failure had the potential for resident harm and/or death, due to CDPH ' s inability to promptly investigate the possibility of resident abuse in the facility. This delayed CDPH response to ensure Resident 1 was safe and free from possible abuse and/or mistreatment in the facility and had the potential for other unusual occurrences to go unreported. Findings: During a review of Resident 1 ' s admission Record (the front page of the chart that contains a summary of basic information about the resident), dated 5/19/2025, the admission Record indicated, the facility originally admitted Resident 1 on 2/28/2024, then re-admitted Resident 1 on 5/8/2025, with diagnoses that included age-related osteoporosis (weak and brittle bones due to lack of calcium and vitamin D) without current pathological fracture (broken bone caused by disease), dementia (a progressive state of decline in mental abilities), and contracture of the right knee (the tissues around the joint have become stiff or tight, limiting the knee's ability to move freely). During a review of Resident 1 ' s History and Physical, dated 5/9/2025, the H&P indicated Resident 1 did not have the capacity to understand nor make decisions. During a review of Resident 1 ' s Minimum Data Set, (MDS — a federally mandated resident assessment tool), dated 2/24/2025, the MDS indicated, Resident 1 was dependent on assistance (helper performs all the effort. Resident did none of the effort to complete the activity. Or the assistance of two or more helpers was required for the resident to complete the activity). During a review of Resident 1 ' s Radiology Result Report X-ray (a photograph of the internal composition of a body part) of the right knee, dated 5/4/2025, the report indicated Resident 1 had an acute mildly displaced supracondylar fracture of the distal femur. During a review of Resident 1 ' s Progress Notes, dated 5/6/2025, the documentation indicated the results of Resident 1 ' s X-ray were reported to the facility on 5/4/2025. During a review of the facility ' s fax transmittal document, dated 5/7/2025, the document Page 1 of 2 055531 055531 05/19/2025 Beachside Post Acute 22520 Maple Avenue Torrance, CA 90505

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated the facility reported the unusual occurrence regarding Resident 1 to CDPH on 5/7/2025 at 8:51 p.m. During an interview on 5/19/2025 at 3:27 p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated the results of Resident 1 x-ray should have been reported to CDPH within 24 hours of the facility becoming aware of the results. RNS 1 stated the failure to report unusual occurrences or test results within the required timeframe could have further jeopardized Resident 1 ' s well-being. During a concurrent interview and record review on 5/19/2025 at 3:27 p.m. with the Director of Nursing (DON), the fax transmittal document, dated 5/7/2025, and Resident 1 ' s Radiology Result Report X-ray, dated 5/4/2025, were each reviewed. The DON stated Resident 1 ' s x-ray results should have been reported to CDPH as soon as the facility became aware of the results and no later than 24 hours. The DON stated unusual occurrences should be reported as soon as possible, but not later than 24 hours. The DON stated the results of Resident 1 ' s x-ray were not reported to CDPH until 5/7/2025 but should have been sent on 5/5/2025 instead. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation — Reporting and Investigating, revised 3/24/2025, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported: . 5. Immediately is defined as:a. within two hours of an allegation involving abuse or resulting in physical harm/serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in physical harm/serious bodily injury. During a review of the facility ' s policy and procedure titled, Unusual Occurrence Reporting, revised 12/2007, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors: . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 055531 Page 2 of 2