Other·December 2, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for FACILITY REPORTED INCIDENT (FRI) No. CA00704492. Inspection was limited to the specific FRI investigated and did not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyors 29461, HFEN and 42906, HFEN. FOR FRI No. CA00704492: THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE FRI ALLEGATION. FINDINGS WERE CITED AT F689 FOR RESIDENT 1. GLOSSARY OF ABBREVIATIONS & BRIEF DEFINITIONS: Autopsy - post-death examination to discover the cause of death or the extent of the disease CNA - Certified Nursing Assistant Code Blue - urgent medical emergency, usually a resident in cardiac or respiratory arrest dementia - a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning Coroner - an official who investigates violent or suspicious death Heimlich maneuver - abdominal thrusts, first aid procedure, to treat upper airway obstruction or choking by foreign objects LVN - Licensed Vocational Nurse Mechanical Soft Diet - diet designed for people who have trouble chewing and swallowing LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 1 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE MDS - Minimum Data Set (a standardized assessment tool) P&P - policy and procedure POLST - Physician Orders for Life-Sustaining Treatment RD - Registered Dietitian RN - Registered Nurse SBAR - situation, background, assessment, recommendation (a system for documenting and communicating changes in a resident's condition) ST - Speech Therapist/Speech Therapy Vital signs - clinical measurements including temperature, pulse, respiration, blood pressure, to indicate the state of a resident's essential body functions

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, facility P&P review, and coroner's autopsy report review, the facility failed to provide the necessary interventions to assist one of two sampled residents (Resident 1) during a lifethreatening emergency. * Resident 1 was in her room while eating FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 2 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE breakfast when she began choking on her meal. LVN 4 was in the room assisting Resident 1's roommate and observed the resident choking. The facility failed to attempt to notify the emergency medical services (911) when their efforts to clear the food bolus blocking Resident 1's airway was unsuccessful. This failure contributed to Resident 1's untimely death. Findings: Review of the facility's P&P titled Emergency Procedure-Choking dated August 2018 showed the trained staff will assist the resident who is choking by attempting to expel the foreign body from the airway. If unable to clear the foreign body from obstructing the resident's airway, arrange the emergency transport of the resident to the nearest acute care hospital emergency department. Closed medical record review for Resident 1 was initiated on 9/10/2020. Resident 1 was admitted to the facility on 10/11/18, with diagnoses, including unspecified dementia with behavioral disturbance and dysphagia (difficulty swallowing). Review of Resident 1's history and physical examination dated 12/12/19, showed Resident 1 did not have the capacity to understand and make decisions. Review of Resident 1's MDS dated 7/21/2020, showed Resident 1 had moderate cognitive impairment. Review of Resident 1's plan of care showed a care plan problem initiated on 9/2/2020, addressing the resident's risk of aspiration/choking distress related to diagnosis of dysphagia. One of the care plan approaches FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 3 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was for Resident 1 to have supervision during meals due to episodes of difficulty swallowing. On 8/18/2020, the facility initiated an SBAR for Resident 1 for coughing/choking while eating lunch. The SBAR documentation showed Resident 1 was observed at 1230 hours coughing out liquidly fluid, mainly water, and carrots that were chopped. Resident 1's physician was notified and an order was received for ST evaluation. Resident 1's family member, who was identified as the resident's responsible party, was informed about the coughing and choking. The SBAR showed Resident 1's responsible party had forgotten to inform the facility Resident 1 was allergic to carrots. On 8/18/2020, the ST evaluation was conducted for Resident 1. The ST documentation showed Resident 1 was on "regular diet." Resident 1 was assessed by the ST with eating a regular diet and thin liquid trial. The ST documented Resident 1 demonstrated slight slow mastication (chewing) but was able to clear. On 9/1/2020, the facility initiated an SBAR for Resident 1 having difficulty swallowing. Documentation on 9/1/2020 at 1800 hours, showed Resident 1 was noted coughing during dinner and had gurgling sound after drinking the liquids. Resident 1's physician was notified, and a physician's order was received to change (downgrade) Resident 1's diet from regular to mechanical soft. A physician's order was received on 9/2/2020, for ST evaluation. Review of the Swallow Evaluation dated 9/3/2020, showed the evaluation was completed by the ST. The ST notes showed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 4 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 was on mechanical soft diet, with her own teeth, and the nursing staff noted increased coughing difficulty, which tended to be in the evening. The ST documented during the evaluation, Resident 1 kept talking about coughing or choking while eating and not wanting to eat. The ST documented Resident 1 kept trying to extend her head back while drinking, and the ST had to physically hold the resident's head in neutral position. In addition, Resident 1 had slow mastication (chewing) and was talking with food in her mouth. Resident 1 demonstrated moderate oral phase deficits and poor safety swallow strategies, which increased the risk for aspiration while eating. Additional review of the Swallow Evaluation dated 9/3/2020, showed documentation from the ST the nursing staff had charted over the past two nights that Resident 1 had difficulty swallowing and was coughing throughout the evening meal last evening. The evaluation also showed Resident 1 demonstrated slow mastication and poor bolus management with unsafe swallowing practices such as extension of head back to help with swallowing. The evaluation notes showed the nursing staff downgraded the resident's diet to mechanical soft, but Resident 1 was still coughing. The ST recommended to continue working with the resident to determine the safest diet for Resident 1, along with providing education to the resident, staff, and the resident's family for safe swallow strategies. Review of the form titled Part B Therapy Request Form showed a request was made on 9/3/2020, for Resident 1 to have the ST due to a change in condition related to difficulty swallowing. The form showed Resident 1 was evaluated two weeks earlier. The documentation showed Resident 1's current function was noted by the nursing staff as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 5 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE having difficulty eating her meals as evidenced by increased coughing. On 9/9/2020, the facility initiated a new SBAR for Resident 1 due to episode of choking while eating breakfast. The staff documented on 9/9/2020 at 0750 hours, Resident 1 was eating breakfast in bed while sitting upright. Resident 1 was witnessed to choke by LVN 4 who was feeding Resident 1's roommate and providing supervision to Resident 1. LVN 4 reported she noticed Resident 1 coughing and then started choking. LVN 4 called for help, removed some food from Resident 1's mouth, and tapped Resident 1's back multiple times. The documentation showed more staff came into Resident 1's room to assist and attempted the Heimlich maneuver, abdominal thrusts, and called a Code Blue. Documentation showed RN 1 went inside Resident 1's room, and Resident 1 was unresponsive and face was turning blue. RN 1 removed more food. Resident 1 clenched her teeth. RN 1 suctioned Resident 1's mouth and obtained yellow particles. RN 1 suctioned Resident 1's nose and obtained white thick mucus. Resident 1's facial color returned to normal, and she moved her head but remained unresponsive. There was no blood pressure, respiratory rate, heart rate. The staff had continued oral and nasal suctioning until nothing was obtained. At 0812 hours, the resident's pupils were dilated and the vital signs were not present. On 9/10/2020 at 1314 hours, a list of the food items served to Resident on her breakfast tray on 9/9/2020 was received from the Administrator. Resident 1 was served with coffee, nonfat milk, oatmeal, scrambled eggs, corn tortilla with margarine, salsa, and sugar substitute. On 9/10/2020 at 1335 hours, an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 6 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with the facility's RD. The RD was asked if Resident 1 had swallowing difficulties, was pocketing of food, or exhibited choking episodes in the past. The RD stated there was an episode of prolonged mastication. The RD stated on 9/1/2020, a CNA reported Resident 1 was having more chewing difficulty and more throat clearing and had episodes of confusion, but Resident 1 denied having any problems. The RD stated she was still in the facility at the time and intervened by downgrading Resident 1's diet to mechanical soft and recommending ST evaluation. The RD was asked if she knew what Resident 1 may have choked on, she stated she did not know. The RD stated she saw what was left on Resident 1's breakfast tray because she had to get it for the coroner. The RD stated Resident 1's breakfast tray had no more tortilla, some of the eggs were gone, the oatmeal looked like it was not touched, the milk was gone, and the coffee was full. On 9/10/2020 at 1405 hours, an interview was conducted with CNA 4. CNA 4 stated she was assigned to Resident 1 on 9/9/2020. CNA 4 stated the breakfast trays were already out when she arrived at the facility. CNA 4 stated she made sure Resident 1 was pulled up in bed, head of bed was high, as high as it could go, and a pillow was behind Resident 1. CNA 4 stated she served Resident 1's breakfast tray. CNA 4 was asked if Resident 1 needed assistance with feeding. CNA 4 stated no, and Resident 1 was a setup only. CNA 4 stated Resident 1's meal tray contained scrambled eggs, corn tortilla, hot salsa, coffee, and milk. CNA 4 stated she did not remember the exact time she served the breakfast tray to Resident 1 but recalled LVN 4 was in the room assisting Resident 1's roommate with feeding. CNA 4 stated she checked on Resident 1 after she passed the breakfast trays to the other residents and observed Resident 1 making a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 7 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE little breakfast taco. CNA 4 stated she asked Resident 1 if she wanted coffee and gave the resident coffee and sugar. CNA 4 stated when she left the room, Resident 1 was fine, and LVN 4 was still in the room. CNA 4 stated she was feeding another resident when CNA 5 came to get her. CNA 4 stated she ran right away to Resident 1's room and found Resident 1 sitting up in bed and her face was turning purple. CNA 4 stated she started performing the Heimlich maneuver (a technique used to expel a trapped object from a person's airway). CNA 4 stated it was very difficult to do the Heimlich maneuver with the resident in bed. CNA 4 stated RN 1 came into Resident 1's room and started suctioning the resident. CNA 4 was asked if 911 was called, CNA 4 stated there were no paramedics, but the staff did not stop the Heimlich maneuver until Resident 1 took her last breath. On 9/10/2020 at 1427 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 1 was a little confused, but was able to follow simple directions. CNA 5 stated Resident 1 did not need assistance with feeding, but needed setup with the meal tray and adding sugar to her coffee. CNA 5 stated Resident 1 did not need her food to be cut up or chopped since Resident 1 liked it whole. CNA 5 stated they were not in Resident 1's when the resident was choking. CNA 5 was assigned to care for Resident 1's roommate, and when she went into the room on 9/9/2020, she observed LVN 4 at Resident 1's bedside, and LVN 4 was calling Resident 1's name. The resident's face was bluish/purple. CNA 5 stated LVN 4 was trying to push Resident 1's stomach and straightening Resident 1's back. CNA 5 stated before entering the room, she heard Resident 1 coughing and sounded like she was trying to clear her throat. CNA 5 stated she yelled for CNA 4 who was in a room across the hallway. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 8 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN 4 paged Code Blue, and everybody came to Resident 1's room. CNA 5 stated LVN 4 and CNA 4 performed the Heimlich maneuver. On 9/10/2020 at 1145 hours, an interview was conducted with RN 1. RN 1 stated she was the supervisor on duty when Resident 1's choking incident occurred. RN 1 stated she heard Code Blue being paged at around 0800 hours. RN 1 stated Resident 1 was lying flat in bed and observed CNA 6 performing chest compressions and abdominal thrusts. RN 1 stated the staff performed the Heimlich maneuver for approximately 10 minutes and RN 1 observed Resident 1's face turned blue, but no food was not coming out. CNA 4 and LVN 4 helped RN 1 to open Resident 1's mouth and suctioned Resident 1. RN 1 stated she retrieved yellow food particles like eggs and corn tortilla. RN 1 stated Resident 1 was still unresponsive, and she suctioned Resident 1's nose. RN 1 stated she suctioned white thick mucus. RN 1 stated Resident 1's face returned to a normal color, but the staff were not able to obtain any vital signs. RN 1 stated she continued to suction Resident 1 until she could not get anything. Resident 1's pupils were dilated and was pronounced dead at 0812 hours. RN 1 was asked if anyone called 911. RN 1 stated she did not attempt to call the paramedics because Resident 1 was a DNR. On 9/10/2020 at 1630 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the ST. The ST was asked about Resident 1 and the ST evaluation conducted on 9/3/2020, which identified Resident 1 was coughing while eating, and the ST was to request authorization for further ST treatment. According to the ST, Resident 1's insurance required prior authorization before therapy could be done. The ST stated Resident 1 had two choking FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 9 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE episodes on two different occasions, and the ST wanted to assess the resident further to make a determination on the Resident 1's diet. The ST stated there was a concern identified on 9/3/2020, and a request for further treatment authorization was faxed to the resident's insurance. The ST stated Resident 1 as unsafe with swallowing and she needed to be supervised with eating meals. On 9/10/2020 at 1725 hours, review of the facility's P&P on Choking and concurrent interview was conducted with the DON. The DON stated Code Blue was paged because of Resident 1's choking incident. The DON stated the staff were performing the Heimlich maneuver and suctioning the resident, but Resident 1 passed away. The DON was asked why the 911 was not called. The DON stated the staff were suctioning the Resident 1 and she was getting her oxygen. The DON stated Resident 1 was a DNR, which was why the paramedics (911) were not notified. The DON then stated Resident 1 had no vital signs, which was also why the paramedics were not notified. The DON stated the staff was able to remove the foreign body since they could not get anything else from Resident 1's mouth. However, Resident 1 no longer had vital signs, she was a DNR status, and therefore, the paramedics were not called. On 9/14/2020 at 1417 hours, a telephone interview was conducted with LVN 4. LVN 4 stated Resident 1 was able to feed herself but needed supervision because she had difficulty swallowing, and therefore, somebody needed to be with Resident 1. LVN 4 stated on 9/9/2020 at around 0750 hours, while she was assisting Resident 1's roommate with breakfast, LVN 4 noticed Resident 1 was having a hard time swallowing her food. Resident 1 was observed closing her mouth FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 10 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and was trying to grab something. LVN 4 said she was not sure what Resident 1 was trying to reach out for but Resident 1 was trying to cough out something. LVN 4 stated she responded immediately by calling out Resident 1's name. Resident 1 was not talking. Resident 1 continued to extend her hand trying to grab something. LVN 4 stated she kept asking Resident 1 if she was okay, but Resident 1 did not respond verbally. LVN 4 stated all of a sudden, she saw food coming out of Resident 1's nose and mouth. LVN 4 stated she was trying to tap Resident 1's back multiple times, but Resident 1 could not talk and her face turned blue. LVN 4 stated she tried to open Resident 1's mouth, but she could not do it because Resident 1 was clenching her teeth. LVN 4 was asked if she initiated the Heimlich maneuver. LVN 4 stated she was supposed to, but Resident 1 was a big lady and she was a small person and could not initiate the Heimlich maneuver. LVN 4 stated it was hard for her to move Resident 1 forward, but she tried her best to put her hand in between Resident 1's back and the mattress. LVN 1 stated CNA 5 tried to tap on Resident 1's back as well. LVN 4 was asked if there was anything else that could have been done when a resident was choking. LVN 4 stated the Heimlich maneuver was initiated, but she was more focused on grabbing a suction machine so she left Resident 1 and paged Code Blue from the nurse's station and grabbed a suction machine. LVN 4 stated when she came back to Resident 1's room, CNA 4, CNA 6, RN 1, and the DON were in the room. LVN 4 was asked if she called the paramedics. LVN 4 stated no. LVN 4 was asked why the paramedics were not notified. LVN 4 stated she was already assisting back and forth and did not really get a chance to call the paramedics. LVN 4 was asked if she should have called the paramedics. LVN 4 stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 11 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE should have but missed to do that because everything happened so fast. Review of Resident 1's POLST showed Do Not Attempt Resuscitation/DNR [Allow Natural Death], Selective Treatment-goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubated. May use noninvasive positive airway pressure. Generally avoid intensive care. On 9/28/2020 at 1240 hours, a telephone interview was conducted with Resident 1's physician. The physician was asked if he had been notified regarding Resident 1's swallowing difficulty and choking episodes. The physician stated he was notified and ordered ST evaluation. The physician was asked about Resident 1's unsafe swallowing identified by the ST during their evaluation conducted on 9/3/2020. The physician stated the resident's swallowing difficulty was not so much about foods but rather liquids. The physician was asked if he considered choking as a medical emergency. The physician stated yes. The physician was asked if the nurses should have called the paramedics to intervene regardless of Resident 1's DNR status. The Resident 1's POLST was read to the physician. The physician responded, "Choking by itself is not enough reason to call 911 immediately because nurses have a chance to intervene. However, when the resident becomes pulseless, they need to call 911. Giving someone a Heimlich does not necessarily mean resuscitating the person, but more of clearing what is obstructing the resident's airway. DNR does not mean do not call 911. In this case, the staff needed to have called the paramedics, regardless of the DNR status, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 12 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE because the POLST was not comfort care. On 9/29/2020 at 1439 hours, a telephone interview was conducted with Family Member 1, Resident 1's Responsible Party. Family Member 1 was asked regarding her understanding of Resident 1's POLST. Family Member 1 stated she remembered she signed the POLST document in the event that the resident stopped breathing, Resident 1 would not be revived, placed on a ventilator, and in the event that she stopped eating there would be no feeding tubes used to feed her. Family Member 1 was asked if she remembered what happed to Resident 1 on 9/9/2020. Family Member 1 stated she received a telephone call at 0830 hours, informing her Resident 1 had choked on food at around 0800 hours and passed away. Family Member 1 was asked if she would have wanted the facility to have called her while Resident 1 was choking, she stated yes. Family Member 1 was asked if she would have wanted the facility to have called the paramedics when Resident 1 was choking, she stated yes because she wanted the paramedics to help Resident 1. Review of the facility's follow-up letter to the Department dated 9/10/2020, showed Resident 1's choking incident took place on 9/9/2020 at around 0750 hours. A licensed nurse was assisting Resident 1's roommate and observed Resident 1 having difficulty swallowing her food and coughing. The licensed nurse immediately assisted Resident 1 by trying to swipe some of her food out of her mouth, but Resident 1 was clenching her teeth, making it impossible for the licensed nurse to do so. The licensed nurse tapped Resident 1's back and called for assistance which came in right away. The nurses started to suction her and performing the Heimlich maneuver, but Resident 1 became unresponsive and the vital signs were no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 13 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555388 (X3) DATE SURVEY COMPLETED 10/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACH CREEK POST-ACUTE 645 S Beach Blvd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE longer detected. The resident had a DNR order. Review of the coroner's autopsy report dated 9/11/2020, showed Resident 1 had expired on 9/9/2020 at 0812 hours, and the cause of death was choking. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M5S11 Facility ID: CA060000923 If continuation sheet 14 of 14