Health inspection·May 3, 2023

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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P specific to an investigation for an injury of unknown source for one of two sampled residents (Resident 1). Residents Affected - Few * Resident 1 sustained a fracture of his right second metacarpal from an unknown source. * Resident 1's family member claimed and informed the facility that Resident 1 sustained a fall in the facility on 2/18/23 at approximately 1815 to 1830 hours. * The facility conducted an investigation specific to Resident 1's fracture (an injury of unknown source), however, failed to investigate Resident 1's family member's claim that Resident 1 fell in the facility on 2/18/23 at approximately 1815 to 1830 hours. The failure to conduct a thorough investigation placed the resident at risk for further injury. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting revised 7/2021 showedall reports of injuries of unknown source shall be reported to the state agency and thoroughly investigated by facility management. If an incident of injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The individual conducting the investigation will, at a minimum: Review the resident's medical record to determine events leading up to the incident. Interview the person(s) reporting the incident. Interview any witnesses to the incident. Interview the resident (as medically appropriate). Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interview the resident's roommate, family members, and visitors. Review all events leading up to the incident. The Administrator will provide the appropriate agencies with a written report of the findings of the investigation within five working days of the occurrence of the incident. Review of the facility's P&P titled Accidents and Incidents – Investigating and Reporting revised 7/2017 showed all accidents or incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor, Charge Nurse and/or Department Director shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form: The date and time the accident or incident took place. The nature of the injury (e.g., fall). The circumstances surrounding the accident or incident. Where the accident or incident took place. The name(s) of witnesses and their accounts of the accident or incident. The injured person's account of the accident or Page 1 of 3 555388 555388 05/03/2023 Beach Creek Post-Acute 645 South Beach Blvd. Anaheim, CA 92804

F 0610 incident. Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 1 was initiated on 4/19/23. Resident 1 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 1's H&P dated 9/7/22, showed Resident 1 had the capacity to understand and make decisions. Resident 1 had a diagnosis of CVA with CNS deficits. Review of Resident 1's care plan problem titled Communication Deficits initiated 9/9/22, showed Resident 1 had expressive aphasia. Review of Resident 1's care plan problem titled At Risk for Fall or Injury initiated 9/7/22, showed Resident 1 had impaired balance during transitions related to the right sided weakness due to CVA. On 4/19/23 at 1150 hours, an observation was conducted of Resident 1. Resident 1 was observed lying in his bed. Resident 1 was nonverbal. Resident 1's room was observed with bilateral floor mats in place located adjacent to each side of his bed. Review of Resident 1's SBAR Communication Form and Progress Note dated 4/5/23 1656 hours, showed Resident 1's sister complained to thefacility's Office Manager that Resident 1 had a fall incident on 2/18/23 (around 1815 to 1830 hours) when transferring (with the assistance of Resident 1's brother-in-law and a CNA) from his chair to his bed. Review of Resident 1's IDT dated 4/7/23, showed an IDT was held regarding the fall claimed by Resident 1's sister. Resident 1's sister stated Resident 1 fell on 2/18/23, while thefamily was visiting. Subsequently, a recommendation for an x-ray of Resident 1's right wrist was made. Review of Resident 1's Radiology Interpretation dated 4/7/23, showed Resident 1 sustained a spiral undisplaced hairline fracture of his right second metacarpal, suggesting acute or subacute finding. Review of Resident 1's medical record for February 2023 failed to show documentation specific to Resident 1's family member's claim that Resident 1 sustained a fall at the facility on 2/18/23 at approximately 1815 to 1830 hours, while a CNA and Resident 1's family member were transferring Resident 1 from a chair to his bed. Review of the facility's investigation (Incident/Accident Investigation Report dated 4/7/23) specific to Resident 1's fracture from an unknown source showed documentation of several interviews conducted with the facility staff. Documentation showed theinterviews were conducted with staff who provided care to Resident 1 during the month of April 2023. However, the facility investigation failed to show the investigation included Resident 1's sister's claim, that Resident 1 had sustained a fall at the facility on 2/18/23 at approximately 1815 to 1830 hours, while a CNA and Resident 1's brother-in-law transferred Resident 1 from his chair to his bed. The facility's investigation failed to show the interviews were conducted with Resident 1's family members, Resident 1's roommates, or the CNA alleged to have assisted Resident 1's family member with transferring Resident 1 when Resident 1 allegedly sustained the fall on 2/18/23 at approximately 1815 to 1830 hours. Additionally, the facility's investigation failed to show the interviews were conducted with the RN and LVN assigned to care for Resident 1 at the time the alleged fall on 2/18/23 at 1815 to 1830 hours. 555388 Page 2 of 3 555388 05/03/2023 Beach Creek Post-Acute 645 South Beach Blvd. Anaheim, CA 92804

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/19/23 at 1500 hours, an interview, medical record review, and concurrent facility document review was conducted with the Administrator. The Administrator stated he conducted oversite of the facility's investigation of Resident 1's injury of unknown source. The Administrator stated the investigation should include any viable source, that might provide information which could determine the cause of Resident 1's fracture. The Administrator stated he assigned the investigation to the DON. The Administrator reviewed the facility's investigative findings and verified the staff interviewed by the DON were questioned specific to whether Resident 1 sustained a fall in the Month of April 2023. The Administrator verified Resident 1' SBAR dated 4/5/23 at 1656 hours, showed Resident 1' family member claimed Resident 1 fell at the facility on 2/18/23 at approximately 1815 to 1830 hours. However, the facility's investigation failed to show any information specific to Resident 1 having allegedly fallen on 2/18/23 at approximately 1815 to 1830 hours. The Administrator stated the facility's investigation should have included an interview with Resident 1's family member who claimed Resident 1 fell on 2/18/23, to determine the specifics of Resident 1's alleged fall and if this alleged fall might have caused Resident 1's fracture. On 4/19/23 at 1544 hours, an interview, medical record review, and concurrent facility document review was conducted with the DON. The DON verified she conducted the facility's investigation specific to Resident 1's injury of unknown source (right second metacarpal fracture). The DON reviewed and verified Resident 1's SBAR Communication Form and Progress Note dated 4/5/23 at 1656 hours, showed Resident 1's family member complained to the facility's Office Manager that Resident 1 had a fall incident on 2/18/23 (around 1815 to 1830 hours) when a CNA and Resident 1's family membertransferred Resident 1 from a chair to a bed. The DON then reviewed her investigation (Incident/Accident Investigation Report dated 4/7/23) and verified all staff interviews conducted were focused on whether Resident 1 had fallen in April of 2023. The DON verified her investigation failed to include documentation specific to Resident 1 sister's claim that Resident 1 fell on 2/18/23, at approximately 1815 to 1830 hours. The DON verified the investigation failed to show any interviews were conducted with thestaff, residents, and Resident 1's family membersspecific to Resident 1's family member's claim Resident 1 fell on 2/18/23 at approximately 1815 to 1830 hours. Further review of Resident 1's medical record failed to show documentation Resident 1 was assessed at the time of his alleged fall on 2/18/23 at approximately 1815 to 1830 hours. The DON verified the findings. 555388 Page 3 of 3