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 (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 3 Event ID: 555388 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 555388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Creek Post-Acute 645 South Beach Blvd. Anaheim, CA 92804 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)