Health inspection·September 6, 2023

F 0689 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) with a history of falls remained free from accidents. * The facility failed to ensure the care plan problem was revised to address Resident 1's fall incident on 8/28/23. Resident 1 had another fall on 8/30/23. This failure put Resident 1 at risk for further falls and serious injuries. Findings: Review of the facility's P&P titled Care Plans - Comprehensive revised October 2010 showed assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Closed medical record review for Resident 1 was initiated on 9/1/23. Resident 1 was admitted to the facility on [DATE], and discharged on 8/30/23, to the acute care hospital due to a fall incident. Review of Resident 1's Fall Risk Evaluation dated 8/14/23, showed Resident 1 was a medium risk for falls. The Fall Risk Evaluation dated 8/16/23, showed Resident 1 was a high risk for falls. Review of Resident 1's H&P examination dated 8/15/23, showed Resident 1 had diagnoses including dementia (a loss of memory, language, problem–solving and other thinking abilities that are severe enough to interfere with daily life) and repeated falls among others. Review of Resident 1's Progress Notes, under Change of Condition section showed Resident 1 fell at the facility on 8/15/23 at 0542 and 2315 hours, 8/18, 8/21, 8/28, and 8/30/23. Review of Resident 1's MDS 3.0 Summary dated 8/16/23, showed Resident 1 was cognitively impaired. Further review of the medical record showed Resident 1 required one person assistance with transfersand locomotion. Review of Resident 1's IDT (Interdisciplinary Team – a group of healthcare professionals with various areas of expertise who work together toward the goals of their clients) notes showed Resident 1 got out of bed without calling for assistance and the IDT had provided the fall recommendations such as crash mats (a protective foam pad placed on the ground, used as protection in case of falling), low bed, frequent checks, and room close to nursing station to increase visual checks after Resident 1 fall incidents. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555027 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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)