Other·December 7, 2018

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 Department of Public Health during the investigation of a Complaint. Complaint Number: CA00603264 Representing the Department of Public Health: Surveyor ID: 38550 RN, HFEN The inspection was limited to the specific Complaint investigated and does not represent a full inspection of the facility. Two deficiencies were issued for Complaint Number: CA00603264

F580 SS=G Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 12/07/2018 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's 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: EMC511 Facility ID: CA940000042 If continuation sheet 1 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 2 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 Based on interview and record review, the facility's staff failed to follow its policy, a resident's plan of care, and professional standards of practice for one of three sampled residents (Resident 1). Resident 1, who had a history of hypertension (high blood pressure) and was receiving Metoprolol (a medication used to lower blood pressure) and was not assessed for signs and symptoms of hypotension and the physician was not notified after the resident's blood pressure (BP) dropped to 86/58 millimeters of mercury (mmHG) (Normal Reference Range [NRR] 120/80 mmHg). (Cross referenced to F660). These deficient practices resulted in Resident 1's condition deteriorating, the resident falling and having a syncopal (to pass out) episode and a blood pressure of 70/50 mmHg within 35 minutes of being discharged home. Emergency services were called and Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation and treatment. Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on August 20, 2018. Resident 1's diagnoses included a history of hypertension (high blood pressure), hypotension (low blood pressure), difficulty walking, cardiac pacemaker (a device implanted under the skin to stimulate the heart to beat regularly), generalized muscle weakness and congestive heart failure ([CHF] the heart does not beat as it should). A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated August 29, 2018, indicated a Brief Interview for Mental Status (BIMS) score of 15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 3 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 (12-15 = no impairment), which indicated that Resident 1 did not have problems with memory and cognition (thought process). The MDS indicated Resident 1 required extensive staff assistance with bed mobility and transfers and was totally dependent on staff for locomotion on and off of the unit. A review of Resident 1's physician's order summary report indicated the following: 1. August 20, 2018, an order for Metoprolol Tartrate 25 milligrams (mg) half of a tablet by mouth, twice daily (BID) for hypertension. The medication was to be held for systolic (top number of a blood pressure reading) blood pressure of less than 100 and heart rate of less than 60. 2. August 29, 2018, an order to discharge Resident 1 home with a family member. A review of Resident 1's undated care plan, indicated the resident had hypertension and was receiving an antihypertensive medication (a medication used to lower blood pressure). The staff's interventions included administering an anti-hypertensive medication as ordered, monitoring the resident for medication side effects such as orthostatic hypotension (low blood pressure that occurs when changing positions) and reporting side effects of the medication to the physician. A review of the August 2018 Medication Administration Record (MAR), indicated the following for Resident 1: 1. August 21, 2018, 9 a.m. dose of Metoprolol was held. Resident 1's BP was documented low at 101/69 mmHg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 4 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 2. August 23, 2018, 9 a.m. dose of Metoprolol was held. Resident 1's BP was documented low at 100/86 mmHg. 3. August 23, 2018, 5 p.m. dose of Metoprolol was held. Resident 1's BP was documented low at 101/69 mmHg. 4. August 24, 2018, 9 a.m. dose of Metoprolol was held. Resident 1's BP was documented low at 105/60 mmHg. 5. August 28, 2018, 5 p.m. dose of Metoprolol was held. Resident 1's BP was documented low at 86/58 mmHg. 6. August 29, 2018, 9 a.m. dose of Metoprolol was held. Resident 1's BP was documented low at 90/60 mmHg. There was no documented evidence in Resident 1's medical record to indicate Resident 1 was assessed for signs of hypotension and no documentation of the physician being notified of the resident's low blood pressure for any of the above dates. A review of Resident 1's Weights and Vitals Summary, indicated the following blood pressure readings: 1. August 21, 2018, at 9:31 a.m., 101/69 mmHg. 2. August 23, 2018, at 10:04 a.m., 102/78 mmHg. 3. August 23, 2018, at 3:49 p.m., 100/86 mmHg. 4. August 24, 2018, at 9:44 a.m., 105/60 mmHg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 5 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 5. August 28, 2018, at 7:37 p.m., 86/58 mmHg. 6. August 29, 2018, at 9:58 a.m., 90/60 mmHg. A review of Resident 1's Physician Progress Note, dated August 23, 2018 and timed at 11:57 a.m., indicated Resident 1 was weak after a prior hospitalization and the resident's BP would be closely monitored. A review of Resident 1's Discharge Instructions, dated August 28, 2018 and timed at 12:57 p.m., indicated the resident was to be discharged home from the facility on August 29, 2018. A review of Resident 1's Discharge Summary/Comprehensive Assessment, dated August 29, 2018, indicated Resident 1's BP upon discharge was 90/60 mmHg. A review of the GACH's emergency room (ER) records indicated after Resident 1's discharge from the facility, Resident 1's family member (FM 1) drove the resident home and was attempting to remove the resident from the vehicle when the resident had a fall. According to the ER records, Resident 1 then had a syncopal episode and the family called 911 for emergency services. The ER records indicated upon paramedic arrival at 4:28 p.m., Resident 1's blood pressure was 70/50 mmHg and increased to 86/66 mmHg at 4:45 p.m. Resident 1 was then transferred to the GACH were it was documented that Resident 1 was weak, pale and was diagnosed with syncope. On September 25, 2018 at 12:59 p.m., during a concurrent interview and record review, the facility's Physical Therapist (PT 1) stated Resident 1 was admitted for physical therapy and had initially improved while receiving physical therapy, but prior to being discharged FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 6 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 from the facility, the resident regressed and required the same level of assistance needed when he initially arrived at the facility. PT 1 stated he did not attend the interdisciplinary team ([IDT] a group of different disciplines working together for a common goal of a resident) meetings for residents and was unsure if Resident 1's regression was discussed with the physician and the IDT. On October 19, 2018 at 3:38 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated if a resident had a change in BP that was different from the resident's baseline, the BP was to be rechecked, the resident was to be assessed for signs and symptoms of hypotension and the physician was to be notified right away. According to the DON, staff was to document all interventions in the resident's medical record. The DON stated Resident 1's physician should have been notified (prior to the resident being discharged) of the resident's BP readings of 86/58 mmHg and 90/60 mmHg. The DON was unable to locate any documentation in Resident 1's medical record of the resident being assessed for signs and symptoms of hypotension, of the resident's BP being rechecked, or of the physician being notified of the low BP readings. On October 19, 2018 at 4:40 p.m., during a concurrent interview and record review, Resident 1's physician (MD 1) stated he was not notified by staff of Resident 1's BP prior to discharging the resident home. MD 1 stated it was not safe to discharge Resident 1 home with a BP of 90/50 mmHg and if he had been aware of the BP reading, he would not have sent Resident 1 home. MD 1 stated he would not have continued the dose of Metoprolol and would have canceled the discharge home and sent the resident to the emergency room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 7 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 immediately. MD 1 stated sending Resident 1 home with a BP of 90/50 mmHg could have resulted in the resident passing out. MD 1 stated he did not have access to review resident vital signs and depended on the facility's staff for notification of any abnormal vital signs. According to MD 1, when Resident 1's BP was 86/58 mmHg on the night of August 28, 2018, staff should have immediately called and notified the on-call physician. MD 1 was unable to locate any documentation of himself or the on-call physicians being notified of Resident 1's low blood pressure readings. A review of the facility's policy titled, "Change of Condition Reporting," with a revision date of May 2007, indicated all changes in resident condition were to be communicated to the physician. According to the policy, licensed nurses would notify the primary physician of a resident's change in condition as soon as possible. The policy indicated all nursing actions would be documented in the resident's medical record. A review of the facility's policy titled, "Blood Pressure," with a revision date of May 2007, indicated staff would follow through with any necessary measures for abnormal blood pressure readings.

F660 SS=G Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 12/07/2018 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 8 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 9 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy and ensure a safe and appropriate discharge home for one of three sampled residents (Resident 1). Resident 1, who had a history of hypotension (low blood pressure), was discharged home without staff notifying the physician the resident had repeated low blood pressure readings prior to discharge. (Cross referenced to F580). This deficient practice resulted in Resident 1 falling and passing out within 35 minutes of being discharged home from the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 10 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on August 20, 2018. Resident 1's diagnoses included a history of hypertension (high blood pressure), hypotension (low blood pressure), difficulty walking, cardiac pacemaker (a device implanted under the skin to stimulate the heart to beat regularly), generalized muscle weakness and congestive heart failure ([CHF] the heart does not beat as it should). A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated August 29, 2018, indicated a Brief Interview for Mental Status (BIMS) score of 15 (12-15 = no impairment), which indicated that Resident 1 did not have problems with memory and cognition (thought process). The MDS indicated Resident 1 required extensive staff assistance with bed mobility and transfers and was totally dependent on staff for locomotion on and off of the unit. A review of Resident 1's undated care plan, indicated the resident wished to be discharged home. The staff's interventions included establishing a pre-discharge plan, evaluating the resident's progress, and revising the plan. A review of Resident 1's Discharge Instructions, dated August 28, 2018 and timed at 12:57 p.m., indicated the resident was to be discharged home from the facility on August 29, 2018. A review of Resident 1's Notice of Transfer/Discharge, dated August 29, 2018, indicated the resident was being discharged home because Resident 1's health had improved sufficiently enough that the resident no longer required services provided by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 11 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 facility. A review of Resident 1's Discharge Summary/Comprehensive Assessment, dated August 29, 2018, indicated Resident 1's blood pressure (BP) upon discharge was 90/60 millimeters of mercury (mmHg) (Normal Reference Range [NRR] 120/80 mmHg). The assessment indicated Resident 1 was being discharged with family with a total of 42 pills of Metoprolol (medication used to lower blood pressure). A review of a Nurses Progress Note, dated August 29, 2018, and timed 3:55 p.m., indicated Resident 1 was discharged home with a family member. The note indicated Resident 1 had a safe discharge. A review of the general acute care hospital's (GACH) emergency room (ER) records, dated August 29, 2018, indicated after Resident 1's discharge from the facility, Resident 1's family member (FM 1) drove the resident home and was attempting to remove the resident from the vehicle when the resident had a fall. According to the ER records, Resident 1 then had a syncopal (to pass out) episode and the family called 911 for emergency services. The ER records indicated upon paramedic arrival at 4:28 p.m., Resident 1's blood pressure was 70/50 mmHg and increased to 86/66 mmHg at 4:45 p.m. Resident 1 was then transferred to the GACH were it was documented that Resident 1 was weak, pale and was diagnosed with syncope. On October 19, 2018 at 4:40 p.m., during a concurrent interview and record review, Resident 1's physician (MD 1) stated he was not notified by staff of Resident 1's BP prior to discharging the resident home. MD 1 stated it was not safe to discharge Resident 1 home FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 12 of 13 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: _______________ 055353 (X3) DATE SURVEY COMPLETED 11/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHORELINE HEALTHCARE CENTER 4029 E Anaheim St Long Beach, CA 90804 (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 with a BP of 90/50 mmHg and if he had been aware of the BP reading, he would not have sent Resident 1 home. MD 1 stated he would not have continued the dose of Metoprolol and would have canceled the discharge home and sent the resident to the emergency room immediately. MD 1 stated sending Resident 1 home with a BP of 90/50 mmHg could have resulted in the resident passing out. MD 1 stated he did not have access to review resident vital signs and depended on the facility's staff for notification of any abnormal vital signs. According to MD 1, when Resident 1's BP was 86/58 mmHg on the night of August 28, 2018, staff should have immediately called and notified the on-call physician. MD 1 was unable to locate any documentation of himself or the on-call physicians being notified of Resident 1's low blood pressure readings. A review of the facility's policy titled, "Discharge or Transfer," with a revised date of 5/2007, indicated it was the policy of the facility to provide the Resident with a safe organized structured transfer and or discharge from the facility to include but not limited to hospital, another healthcare facility or home that will meet their highest practical level of medical, physical, and psychosocial well being. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EMC511 Facility ID: CA940000042 If continuation sheet 13 of 13