Other·June 11, 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 of a Complaint Investigation during an Abbreviated Survey. Complaint Number: CA00573294 Representing the Department of Public Health: Surveyor ID: 37393, RN, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. There were two deficiencies issued for CA00573294

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 06/10/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the 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: TDHF11 Facility ID: CA940000097 If continuation sheet 1 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report to the Department of Public Health (DPH) the initial report of multiple falls with injury, within 24 hours, in accordance with State Regulations for one of three sampled residents (Resident 1). This deficient practice had the potential to jeopardize Resident 1 and other residents' who are at risk for falls safety. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 12/28/18. Resident 1's diagnoses included cerebral infarction (a blockage or narrowing in the arteries supplying blood and oxygen to the brain), abnormal posture, leftsided hemiplegia (paralysis [inability to move] one side of the body), and muscle weakness. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 2 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 1/4/17, indicated Resident 1 had no cognitive (ability to think and reason) impairment, and was able to make needs known and understand others. According to the MDS, Resident 1 required extensive assistance with bed mobility, transferring, locomotion on and off the unit, as well extensive assistance with eating and personal hygiene. A review of Resident 1's Fall Assessment, dated 1/18/18, indicated Resident 1 had a score of 23 (total score of above 10 represents high risk for falls). According to the Fall Risk Assessment, Resident 1 had a history of three or more falls within the last three (3) months. A review of Resident 1's care plan titled, "At risk for Injuries from falls ...," indicated the staff's interventions included to monitor the environment for wet spots or items placed below Resident 1's field of vision, keep call light within reach and answer promptly, ensure lighting was adequate, monitor the resident for steadiness and balance, keep bed low with floor mat, and refer to rehab or physician if indicated. A review of Resident 1' physician's order, dated 12/28/17, indicated an order for Norco ([Acetaminophen and Hydrocodone] an opiate pain medication intended to relieve moderate to severe pain) 10/325 milligram (mg) tablet, orally, every 6 hours for pain. A review of Resident 1' physician's order, dated 12/28/17, indicated an order for Hydromorphone ([dilaudid] a narcotic used to help relieve moderate to severe pain apart of a class of drugs known as opioid analgesics) 4 mg tablet, every 4 hours, for severe pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 3 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 A review of the facility's incident report, dated 12/29/17, and timed at 2:30 p.m., indicated Resident 1 was heard yelling and the licensed nurse observed the resident on the floor beside the bed, with the call light within reach. The report indicated Resident 1 was returned back to bed with a Hoyer lift (mechanical lift). Upon assessment, Resident 1 was observed with an abrasion to left second and third toes, with no swelling. According to the report, Resident (Resident 1) had pre-existing left-sided hemiparesis (paralysis), and the resident was educated to use the call light at all times for assistance. A review of the pain assessment flow sheet, dated 12/29/17, and timed at 11:15 p.m., indicated Resident 1 complained of 7 out of 10 pain (scale of 0 to 10, 0 = no pain to 10 = worst) and was administered dilaudid 4 mg. A review of the pain assessment flow sheet, dated 12/30/17, and timed at 2:45 a.m., indicated Resident 1 complained of 7 out of 10 pain and was administered dilaudid 4 mg. A review of the Licensed Personnel Progress Note, dated 12/30/17, and timed at 6:30 a.m., indicated Resident 1 complained of general body pain 7 out of 10 on the pain scale and was administered hydromorphone 4 mg tablet after a recent fall, and was on frequent monitoring for safety for fall precautions. A review of the facility's "SBAR (Situation Background Assessment Recommendation) Communication form," dated 12/30/17, and timed at 3 p.m., indicated Resident 1 had an unwitnessed fall and was found lying on the floor next to the bed. The SBAR communication form indicated Resident 1 had an abrasion to the left foot with throbbing pain 4 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 4 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 out of 10 on a pain scale. The interventions included assisting Resident 1 back to bed with a Hoyer lift and neurological checks (detect the presence of brain injury) with monitoring of its progression for 72 hours post fall. A review of the facility incident report, dated 1/7/18, and timed at 8:40 a.m., indicated Resident 1 was found on the floor by a certified nursing assistant (CNA). The report indicated the CNA notified the on duty Licensed Vocational Nurse and helped transferred Resident 1 back to bed. According to the report, Resident 1 had no visible injuries noted and no complaints of pain. A review of the "SBAR Communication form," dated 1/7/18 and timed at 9:05 a.m., indicated Resident 1 had a second unwitnessed fall and was found lying on the floor on his right side next to the bed with no injury. The SBAR communication form also indicated Resident 1 had back pain 5 out of 10 on a pain scale. A review of the pain assessment flow sheet, dated 1/7/18, and timed at 11 a.m., indicated Resident 1 complained of 8 out of 10 pain and was administered Norco 10/325 mg. A review of the Licensed Personnel Progress Note, dated 1/7/18, shift 3 p.m. to 11 p.m. indicated Resident 1 was on monitoring for status post fall. A review of the pain assessment flow sheet, dated 1/8/18, and timed at 4 a.m., indicated Resident 1 complained of 8 out of 10 pain and was administered Norco 10/325 mg. A review of the facility incident report, dated 1/8/18, and timed at 10:45 a.m., indicated Resident 1 had a witnessed fall in front of the nursing station from his wheelchair and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 5 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 sustained a laceration to his upper lip with bleeding. A review of the Licensed Personnel Progress Note, dated 1/8/18, and timed at 10:45 a.m., indicated Resident 1 was in front of the nursing station and was seen leaning forward from his wheelchair. The note indicated Resident 1 loss his balance and fell to the floor in the prone (face down) position. Resident 1 sustained a cut to upper lip with bleeding, and complaints of pain 3 out of 10. The note indicated Resident 1 had history of multiple falls, the resident's physician was made aware, with an order for cold compress to both lips, every shift, for 1015 minutes for five days. A review of a "SBAR Communication form," dated 1/8/18, and timed at 10:45 a.m., indicated Resident 1 had a third witnessed fall from his wheelchair. The SBAR indicated Resident 1 sustained a laceration to the upper lip with swelling and bleeding. Resident 1 was administered pain medication and given a cold compress to apply to both lips. A review of the pain assessment flow sheet, dated 1/8/18, and timed at 6:30 p.m., indicated Resident 1 complained of 8 out of 10 pain and was administered dilaudid 4 mg. A review of the Licensed Personnel Progress Note, dated 1/8/18, and timed at 10:40 p.m., indicated Resident 1 was administered dilaudid 4 mg at approximately 6:30 p.m. on 1/8/18, for complaints of body pain. The note indicated to continue to monitor Resident 1 for status post fall. A second facility incident report, dated 1/8/18, and timed at 11:05 p.m., indicated Resident 1 had an unwitnessed fall for the second time on the same day from his bed, sustaining an injury FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 6 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 to the left second and third toes. According to the report, Resident 1 was assisted back to bed by the charge nurse and assigned CNA, and first aid was rendered to the resident's left toes. A review of the Licensed Personnel Progress Notes, dated 1/8/18, and timed at 11:05 p.m., indicated Resident 1 had another fall and sustained injury to the left second and third toes with active bleeding, and first aid was rendered. The note indicated Resident 1 was transferred back to bed with the Hoyer lift. Another "SBAR Communication form," dated 1/8/18, and timed at 11:30 p.m., indicated Resident 1 had an unwitnessed fourth fall on the same day with injury to left second and third toes. The interventions included conducting neurological checks for 72 hours and to place the resident's bed in the low position. A review of the pain assessment flow sheet, dated 1/9/18, and timed at 3:30 a.m., indicated Resident 1 complained of 6 out of 10 pain and was administered Norco 10/325 mg. A review of the facility incident report, dated 1/19/18, and timed at 3:45 p.m., indicated Resident 1 was found on the floor in the prone position on the floor mat next to his bed. The report indicated Resident 1 was assessed immediately after the fall with no visible injury. A review of the pain assessment flow sheet, dated 1/19/18, and timed at 1 a.m., indicated Resident 1 complained of 7 out of 10 pain and was administered dilaudid 4 mg. A review of the Licensed Personnel Progress Note, dated 1/19/18, and timed at 3:45 p.m., indicated Resident 1 denied any pain or discomfort, was in no distress. The note FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 7 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 indicated Resident 1 had pre-existing left-sided hemiparesis secondary to stroke. According to the note, Resident 1 was returned back to bed with help from staff, with frequent visual checks provided and bed in the low position with floor mats properly placed. Another "SBAR Communication form," dated 1/19/18, and timed at 3:45 p.m., indicated Resident 1 had a unwitnessed fall from his bed and was found in prone position beside his bed on the floor mat with call light nearby. The interventions included conducting neurological checks for 72 hours post fall. A review of the physician's telephone order, dated 2/2/18, and timed at 10 a.m., indicated a left foot x-ray for Resident 1 was ordered per the family's request. A review of the radiology report, dated 2/2/18, and timed at 4 p.m., indicated non-displaced fractures (broken bone) at the base of the fourth and fifth proximal phalanges (toes) of the left foot for Resident 1. A review of the physician's telephone order, dated 2/8/18, and timed at 9:30 a.m., indicated Resident 1 was to be transferred to the general acute care hospital (GACH) for further evaluation due to left foot fourth and fifth nondisplaced toes fractures. A review of the physician's telephone order, dated 2/8/18, and timed at 8:10 p.m., indicated to resume all of Resident 1's orders, discontinue the orthopedic consultation, discontinue heel protectors and immobilize left fourth and fifth left toes with tape treatment as needed for Resident 1. On 2/22/18 at 10:44 a.m., during an interview, Resident 1's family member (FM 1) stated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 8 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 "When he (Resident 1) was admitted he fell out of his bed and hit his toes. He has left-sided paralysis and has no bedrails on his bed. The next day his toes were discolored, I was concerned because he complained of pain. It took six weeks for the facility to order an x-ray and he had left fractured (broken bones) toes. He was given a lot of pain medication but the facility did not look at his feet." On 2/26/18 at 11:40 a.m., during a phone interview, the Ombudsman (an official appointed to investigate individuals' complaints against maladministration, especially that of public authorities) stated, "The family member for the resident (FM 1) contacted me because the resident's toes were discolored and the facility did not address the family member's (FM 1) concerns. I had a care plan meeting with the facility and the family member (FM 1). An x-ray was finally ordered and it was discovered that his toes were broken." On 2/26/18 at 1:28 p.m., during an interview, Resident 1 stated, "I have fallen from my bed a few times, my foot was painful and bruised, and they never checked my foot. I could not stand during physical therapy because of the foot pain, so my therapy was cancelled." On 2/26/18 at 3:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated, "When the resident fell on December 30th he was given pain medication; there was only an abrasion on his foot with pain. I did not see any bruising; he puts himself on the floor for attention. He does not use the call light for any help. He has left sided paralysis, but we do not place side rails because we do not want to restrain him. He has a mat next to his bed." On 2/28/18 at 8:59 a.m., during an interview, LVN 1 stated, "The resident has had several FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 9 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 falls; I cannot remember the exact number, less than 10 falls. He rolls out of bed intentionally, and falls on his side, he does not use the call light. He just yells nurse. I do not know if he fractured his toes the day he was complaining of throbbing pain on his left foot. The reason we got an x-ray was because his family member kept asking for an x-ray because of the discoloration, saying his toes were black. For residents who fall we move them close to the nursing station. He only complained of general body pain, no complaint of pain of the toes." On 2/28/18 at 9:53 a.m., during an interview, CNA 1 stated, "I do not remember his (Resident 1) toes being dark or having abrasions. I know he has paralysis on the left side." On 2/28/18 at 10:01 a.m., during an interview, CNA 2 stated "The resident (Resident 1) rolls out of bed purposely for attention, I help get him back into bed, it takes four of us to get him back into bed. I did not notice any bruising on his toes or any other injuries." On 2/28/18 at 10:13 a.m., during an interview, CNA 3 stated, "The resident (Resident 1) has fallen out of the bed, I remember him breaking the bedside drawer. He likes attention, I do not remember his toes being bruised or dark or of him complaining of pain, but he fell a lot." On 2/28/18 at 11 a.m., during an interview, the Physical Therapy Director (PTD) stated, "The resident (Resident 1) did have a fall after admission, I assessed him. We met with the family and he received therapy for three weeks before the orders were discontinued. The resident hit a plateau and was not progressing." On 2/28/18 at 11:49 a.m., during and interview, the Director of Nursing (DON) stated, "This FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 10 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 rolls himself out of bed, and is noncompliant with using the call light. We held a care plan meeting about the falls, but did not know about the toe fractures. We did not report the falls because he was found on the floor mat next to his bed. The care plans were updated and incident reports were completed for each fall." A review of the facility's policy titled, "Incident Report," dated 1/2017, indicates incidents involving residents, visitors, or volunteers be recorded on an incident form. An incident was identified as an unusual event or happening with unintended, undesirable, and or unexpected results. According to the policy, when appropriate, the administrator would notify the Department of Public Health and/or Ombudsman by telephone and in writing of reportable incidents and unusual occurrences in a timely manner. A review of the facility's policy titled, "Falls by a Resident," dated 7/2017, indicates if a resident sustains a fall, an incident report will be completed. The policy indicated to identify an action plan of approaches that may be taken in an attempt to prevent further falls based on any identified facts or risk factors. A post fall assessment is also completed to identify factors that may have contributed to the fall. According to the policy, the incident report and post fall assessment should be reviewed by the interdisciplinary team.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/10/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 11 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 §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 and record review, the facility failed to adhere to its policy and the resident's plan of care in prevention of falls by not providing a thorough assessment for one of three sampled residents (Resident 1), who had a high risk for falls with a history of multiple falls, had four falls within a 24-hour period. These deficient practices resulted in Resident 1 falling on multiple occasions, sustaining a lip laceration (deep cut) and fractures (broken bones) of the left fourth and fifth proximal phalanges (toes). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 12/28/18. Resident 1's diagnoses included cerebral infarction (a blockage or narrowing in the arteries supplying blood and oxygen to the brain), abnormal posture, leftsided hemiplegia (paralysis [inability to move] of one side of the body), and muscle weakness. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 1/4/17, indicated Resident 1 had no cognitive (ability to think and reason) impairment, and was able to make needs known and understand others. According to the MDS, Resident 1 required extensive assistance with bed mobility, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 12 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 transferring, locomotion on and off the unit, as well extensive assistance with eating and personal hygiene. A review of Resident 1's Fall Assessment, dated 1/18/18, indicated Resident 1 had a score of 23 (total score of above 10 represents high risk for falls). The fall assessment indicated Resident 1 had a history of three or more falls within the last three (3) months. A review of Resident 1's care plan titled, "At risk for Injuries from falls ...," indicated the staff's interventions included to monitor Resident 1's environment for wet spots or items placed below field of vision, keep call light within reach and answer promptly, ensure lighting was adequate, monitor the resident for steadiness and balance, keep bed low with floor mat, and refer to rehab or physician if indicated. A review of the facility's incident report, dated 12/29/17, and timed at 2:30 p.m., indicated Resident 1 was heard yelling and the licensed nurse observed the resident on the floor beside the bed, with the call light within reach. The report indicated Resident 1 was returned back to bed with a Hoyer lift (mechanical lift). Upon assessment, Resident 1 was observed with an abrasion to left second and third toes, with no swelling. According to the report, Resident (Resident 1) had pre-existing left-sided hemiparesis (paralysis), and the resident was educated to use the call light at all times for assistance. A review of the Licensed Personnel Progress Note, dated 12/30/17, and timed at 6:30 a.m., indicated Resident 1 was on frequent monitoring for safety for fall precautions. A review of the "SBAR (Situation Background FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 13 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 Assessment Recommendation) Communication form," dated 12/30/17, and timed at 3 p.m., indicated Resident 1 had an unwitnessed fall and was found lying on the floor next to the bed. The SBAR communication form indicated Resident 1 had an abrasion to the left foot with throbbing pain 4 out of 10 on a pain scale. The interventions included assisting Resident 1 back to bed with a Hoyer lift and neurological checks (detect the presence of brain injury) with monitoring of its progression for 72 hours post fall. A review of the facility incident report, dated 1/7/18, and timed at 8:40 a.m., indicated Resident 1 was found on the floor by Certified Nursing Assistant 1 (CNA 1). The report indicated CNA 1 notified the on duty charge nurse and helped transferred Resident 1 back to bed. According to the report, Resident 1 had no visible injuries noted and no complaints of pain. A review of the "SBAR Communication form," dated 1/7/18 and timed at 9:05 a.m., indicated Resident 1 had a second unwitnessed fall and was found lying on the floor on his right side next to the bed with no injury. The SBAR communication form also indicated Resident 1 had back pain 5 out of 10 on a pain scale. A review of the Licensed Personnel Progress Notes, dated 1/7/18, shift 3 p.m. to 11 p.m. indicated Resident 1 was on monitoring for status post fall. A review of the facility incident report dated 1/8/18 and timed at 10:45 a.m., indicated Resident 1 had a witnessed fall in front of the nursing station from his wheelchair and sustained a laceration to his upper lip with bleeding. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 14 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 A review of the Licensed Personnel Progress Note, dated 1/8/18, and timed at 10:45 a.m., indicated Resident 1 was in front of the nursing station and was seen leaning forward from his wheelchair. The note indicated Resident 1 loss his balance and fell to the floor in the prone (face down) position. Resident 1 sustained a cut to upper lip with bleeding, and complaints of pain 3 out of 10. The note indicated Resident 1 had history of multiple falls, the resident's physician was made aware, with an order for cold compress to both lips, every shift, for 1015 minutes for five days. A review of a "SBAR Communication form," dated 1/8/18, and timed at 10:45 a.m., indicated Resident 1 had a third witnessed fall from his wheelchair. The SBAR indicated Resident 1 sustained a laceration to the upper lip with swelling and bleeding. Resident 1 was administered pain medication and given a cold compress to apply to both lips. A review of the Licensed Personnel Progress Note, dated 1/8/18, and timed at 10:40 p.m., indicated Resident 1 was administered Dilaudid (a narcotic used to help relieve moderate to severe pain) 4 milligrams (mg) at approximately 6:30 p.m. on 1/8/18, for complaints of body pain. The note indicated to continue to monitor Resident 1 for status post fall. A second facility incident report, dated 1/8/18, and timed at 11:05 p.m., indicated Resident 1 had an unwitnessed fall for the second time on the same day from his bed, sustaining an injury to the left second and third toes. According to the report, Resident 1 was assisted back to bed by the charge nurse and assigned CNA, and first aid was rendered to the resident's left toes. A review of the Licensed Personnel Progress FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 15 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 Notes, dated 1/8/18, and timed at 11:05 p.m., indicated Resident 1 had another fall and sustained injury to the left second and third toes with active bleeding, and first aid was rendered. The note indicated Resident 1 was transferred back to bed with the Hoyer lift. Another "SBAR Communication form," dated 1/8/18, and timed at 11:30 p.m., indicated Resident 1 had an unwitnessed fourth fall on the same day with injury to left second and third toes. The interventions included conducting neurological checks for 72 hours and to place the resident's bed in the low position. A review of the facility incident report, dated 1/19/18, and timed at 3:45 p.m., indicated Resident 1 was found on the floor in the prone position on the floor mat next to his bed. The report indicated Resident 1 was assessed immediately after the fall with no visible injury. A review of the Licensed Personnel Progress Note, dated 1/19/18, and timed at 3:45 p.m., indicated Resident 1 denied any pain or discomfort, was in no distress. The note indicated Resident 1 had pre-existing left-sided hemiparesis secondary to stroke. According to the note, Resident 1 was returned back to bed with help from staff, with frequent visual checks provided and bed in the low position with floor mats properly placed. Another "SBAR Communication form," dated 1/19/18, and timed at 3:45 p.m., indicated Resident 1 had a unwitnessed fall from his bed and was found in prone position beside his bed on the floor mat with call light nearby. The interventions included conducting neurological checks for 72 hours post fall. A review of the physician's telephone order, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 16 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 dated 2/2/18, and timed at 10 a.m., indicated a left foot x-ray for Resident 1 was ordered per the family's request. A review of the radiology report, dated 2/2/18, and timed at 4 p.m., indicated non-displaced fractures (broken bone) at the base of the fourth and fifth proximal phalanges (toes) of the left foot for Resident 1. A review of the physician's telephone order, dated 2/8/18, and timed at 9:30 a.m., indicated Resident 1 was to be transferred to the general acute care hospital (GACH) for further evaluation due to left foot fourth and fifth nondisplaced toes fractures. A review of the physician's telephone order, dated 2/8/18, and timed at 8:10 p.m., indicated to resume all of Resident 1's orders, discontinue the orthopedic consultation, discontinue heel protectors and immobilize left fourth and fifth left toes with tape treatment as needed for Resident 1. On 2/22/18 at 10:44 a.m., during an interview, Resident 1's family member (FM 1) stated, "When he (Resident 1) was admitted he fell out of his bed and hit his toes. He has left-sided paralysis and has no bedrails on his bed. The next day his toes were discolored, I was concerned because he complained of pain. It took six weeks for the facility to order an x-ray and he had left fractured (broken bones) toes. He was given a lot of pain medication but the facility did not look at his feet." On 2/26/18 at 11:40 a.m., during a phone interview, the Ombudsman (an official appointed to investigate individuals' complaints against maladministration, especially that of public authorities) stated, "The family member for the resident (FM 1) contacted me because FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 17 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 the resident's toes were discolored and the facility did not address the family member's (FM 1) concerns. I had a care plan meeting with the facility and the family member (FM 1). An x-ray was ordered and it was discovered that his toes were broken." On 2/26/18 at 1:28 p.m., during an interview, Resident 1 stated, "I have fallen from my bed a few times, my foot was painful and bruised, and they never checked my foot. I could not stand during physical therapy because of the foot pain, so my therapy was canceled." On 2/26/18 at 3:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated, "When the resident (Resident 1) fell on December 30th he was given pain medication; there was only an abrasion on his foot with pain. I did not see any bruising; he puts himself on the floor for attention. He does not use the call light for any help. He has left sided paralysis, but we do not place side rails because we do not want to restrain him. He has a mat next to his bed." On 2/28/18 at 8:59 a.m., during an interview, LVN 1 stated, "The resident has had several falls; I cannot remember the exact number, less than 10 falls. He rolls out of bed intentionally, and falls on his side, he does not use the call light. He just yells nurse. I do not know if he fractured his toes the day he was complaining of throbbing pain on his left foot. The reason we got an x-ray was because his family member kept asking for an x-ray because of the discoloration, saying his toes were black. For residents who fall we move them close to the nursing station. He only complained of general body pain, no complaint of pain of the toes." On 2/28/18 at 10:13 a.m., during an interview, CNA 3 stated, "The resident (Resident 1) has fallen out of the bed, I remember him breaking the bedside drawer. He likes attention, I do not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 18 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 remember his toes being bruised or dark or of him complaining of pain, but he fell a lot." On 2/28/18 at 11 a.m., during an interview, the Physical Therapy Director (PTD) stated, "The resident (Resident 1) did have a fall after admission, I assessed him. We met with the family and he received therapy for three weeks before the orders were discontinued. The resident hit a plateau and was not progressing." On 2/28/18 at 11:49 a.m., during and interview, the Director of Nursing (DON) stated, "This resident rolls himself out of bed, and is noncompliant with using the call light. We held a care plan meeting about the falls, but did not know about the toe fractures. We did not report the falls because he was found on the floor mat next to his bed. The care plans were updated and incident reports were completed for each fall." A review of the facility's policy titled, "Incident Report," dated 1/2017, indicates incidents involving residents, visitors, or volunteers be recorded on an incident form. An incident was identified as an unusual event or happening with unintended, undesirable, and or unexpected results. According to the policy, when appropriate, the administrator would notify the Department of Public Health and/or Ombudsman by telephone and in writing of reportable incidents and unusual occurrences in a timely manner. A review of the facility's policy titled, "Falls by A Resident," dated 7/2017, indicates if a resident sustains a fall, an incident report will be completed. The policy indicated to identify an action plan of approaches that may be taken in an attempt to prevent further falls based on any identified facts or risk factors. A post fall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 19 of 20 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: _______________ 055123 (X3) DATE SURVEY COMPLETED 05/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEACHSIDE POST ACUTE 3294 Santa Fe Ave Long Beach, CA 90810 (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 assessment is also completed to identify factors that may have contributed to the fall. According to the policy, the incident report and post fall assessment should be reviewed by the interdisciplinary team. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TDHF11 Facility ID: CA940000097 If continuation sheet 20 of 20