Other·July 5, 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: CA00576998 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 CA00576998

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

F609 06/15/2018 §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 administrator of the facility and to other officials 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: GTZW11 Facility ID: CA940000097 If continuation sheet 1 of 14 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 06/05/2018 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 (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 follow its policy by not investigating and reporting to the Department of Public Health Services (DPH), within two (2) hours in accordance with State Regulations, an injury of unknown origin for one of three sampled residents (Resident 1). This deficient practice had the potential to jeopardize Resident 1's and other residents' safety within the facility. Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on 1/9/18. Resident 1's diagnoses included generalized muscle weakness, diabetes ([DM] high blood sugar), hypertension (high blood pressure), and left-sided hemiparesis (inability to move one side of the body). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 2 of 14 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 06/05/2018 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 124/18, indicated the resident had no memory problems, was able to make needs known and understand others. The MDS indicated Resident 1 was assessed as having functional limitation in range of motion of the upper and lower extremities on both sides of the body. The MDS indicated Resident 1 was dependent with bed mobility, transferring, locomotion on and off the unit, and required assistance with eating and personal hygiene. A review of a licensed nursing note, dated 3/1/18, and timed at 9:45 a.m., indicated two certified nursing assistants (CNAs) observed Resident 1, on the same day, with a slight bluish discoloration of the left upper arm during care. The note indicated Resident 1 complained of mild discomfort to the left upper arm with a pain level 1 to 2 out of 10 (pain scale). According to the note, Resident 1's left arm was contracted (permanent condition of shortening and hardening of muscles, tendons, leading to deformity and rigidity of joints) and the resident kept the arm towards the chest area. A review of a licensed nursing note, dated 3/1/18, and timed at 10:30 a.m., indicated Resident 1's physician was notified of the resident's bluish discoloration of the left upper arm. A review of a physician telephone order, dated 3/1/18, indicated hold left elbow splint for three days and hold range of motion ([ROM] measurement of movement around a joint) to left upper arm for three days for Resident 1. A review of a physician telephone order, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 3 of 14 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 06/05/2018 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 3/2/18, indicated to administer Resident 1 Tylenol (pain reliever) 650 milligrams (mg) orally for management of the left shoulder and arm pain, (325 mg -two tablets). A review of a licensed nursing note, dated 3/2/18, and timed at 3 p.m., indicated Resident 1 remained on monitoring for left upper arm skin discoloration. The note indicated the discoloration was subsiding and Tylenol 325 mg was administered for pain management of the left arm as ordered. A review of a licensed nursing note, dated 3/3/18, and timed at 12 p.m., indicated Resident 1 was on continued monitoring for left upper arm skin discoloration and had no complaints of pain. A review of a licensed nursing note, dated 3/3/18, and timed at 10:10 p.m., indicated Resident 1 was being monitored for left upper arm pain and back bruising with slight swelling and mild pain. A review of a licensed nursing note, dated 3/4/18, and timed at 10:15 p.m., indicated Resident 1 was seen and examined by the physician with no new orders. A review of a therapy progress note, dated 3/5/18, and timed at 10 a.m., indicated Occupational Therapist 1 (OT 1) assessed Resident 1 at the request of the Director of Nursing (DON) due to Restorative Nursing Assistant 1 (RNA 1) observing redness to the resident's left arm. According to the note, OT 1 recommended an x-ray of Resident 1's left shoulder and humerus (long bone in the arm from the shoulder to the elbow) to rule out the cause of the resident's left upper arm discoloration. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 4 of 14 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 06/05/2018 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 a licensed nursing note, dated 3/5/18, and timed at 10:30 a.m., indicated Resident 1 was observed with scattered bruising of the left arm and upper shoulder area. A review of the Situation, Background, Assessment, Recommendation ([SBAR] communication tool used between licensed nurses) communication form, dated 3/5/18, indicated Resident 1's scattered bruising of the left upper arm had gotten worse due to increased discoloration, with increased swelling. The SBAR indicated Resident 1 reported a slightly higher pain level of 5 out of 10 on a pain scale with grimacing (a facial expression usually of disgust, disapproval, or pain). According to the SBAR, Resident 1 was administered routine Tylenol orally and repositioning of the left upper arm. A review of a physician telephone order, dated 3/5/18, and timed at 10:30 a.m., indicated an xray of Resident 1's left shoulder and left humerus. A review of the X-ray results, dated 3/5/18, and timed at 1 p.m., indicated left humerus fracture (broken bone) of the surgical neck, with medial displacement of the distal fragment and medial apex angulation (malposition of the bone from normal location) and mild soft tissue swelling. A review of a pain assessment note, dated 3/5/18, and timed 7 a.m. to 3 p.m. (day shift), indicated Resident 1 had an acute fracture of surgical neck with complaints of pain 5 out of 10. A review of a licensed nursing note, dated 3/5/18, indicated to transfer Resident 1 to the general acute care hospital (GACH) for further evaluation of the left humerus fracture. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 5 of 14 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 06/05/2018 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 During an interview, on 3/15/18 at 10:40 a.m., Resident 1's family member (FM 1) stated, "My family member is paralyzed on the left side from a stroke 20 years ago. The hospital told me she had a humerus fracture on the left side. No one from the facility knows how it happened." On 3/15/18 at 10:54 a.m., during an interview, Resident 1 stated, "I feel fine, my arm hurts a little. No one hurt my arm, I do not know what happened, I just have this thing (sling) to support my arm. I cannot move my arm." On 3/15/18 at 1:06 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated, "She (Resident 1) has a brace on the left side and was receiving ROM on the left side." On 3/15/18 at 1:19 p.m., during an interview, LVN 2 stated, "The CNA reported to me that the resident's left arm and shoulder was bruised. I went with the Registered Nurse (RN) supervisor to look, her (Resident 1) arm was bruised and swollen." On 3/15/18 at 1:35 p.m., during an interview, RN 1 stated, "The resident (Resident 1) has a left flexion contracture. She keeps her left arm close to her body. I only saw discoloration, no swelling. I called the physician and the order was to stop ROM and keep sling on left upper arm and watch for increased bruising or swelling for the next three days. The resident complained of pain 2 out of 10 and had bluish discoloration on the anterior and posterior of the arm. The DON was here and made aware." On 3/15/18 at 2:13 p.m., during an interview, CNA 1 stated, "I was cleaning the resident (Resident 1) and saw discoloration on the left FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 6 of 14 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 06/05/2018 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 arm. I told the charge nurse right away. I did not touch her arm. About three or four days later the bruising got bigger." On 3/20/18 at 11:56 a.m., during a telephone interview, FM 2 stated, "The facility called and told me about the bruise on the left arm. I went to visit two days later and the bruise looked fresh, I told the head nurse to get an X-ray, but if I didn't ask they were not going to get an xray." On 3/20/18 at 3:23 p.m., in the presence of the Administrator (ADM) and Nurse consultant (NC), the DON stated, "The resident (Resident 1) was seen by the doctor on 3/4/18 at 10:30 p.m., and he did not document the evaluation. We did not report to DPH because we did not know it (left arm) was fractured, but an incident report was completed." On 3/22/18 at 2:11 p.m., during a telephone interview, LVN 3 stated, "The family of the resident (Resident 1) was visiting and did request an x-ray for the family member's arm, I told the charge nurse and I'm not sure why she did not document it." A review of the facility's policy titled, "Incident report," dated 1/2017, indicated incidents involving residents, visitors or volunteers would be recorded on an incident form. The policy indicated an incident was an unusual event or happening with unintended, undesirable and/or unexpected results. The policy indicated when appropriate, the Administrator would notify the Department of Public Health and/or the Ombudsman by telephone and in writing of reportable incidents and unusual occurrences in a timely manner. A review of the facility's policy titled, "Abuse reporting and prevention," dated 9/2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 7 of 14 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 06/05/2018 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 to ensure that resident rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences, unauthorized photographs, unauthorized video recordings, unauthorized postings on social media of nursing home residents and misappropriation of resident property. The policy indicated the administrator, or his/her designee would report each alleged abuse to the Ombudsman's office and the Department of Public Health immediately or within 24 hours.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 06/15/2018 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's staff failed to ensure one of three sampled residents (Resident 1) was accurately assessed, and treated after sustaining a bruise on the left upper anterior (front) and posterior (back) arm. This deficient practice resulted in Resident 1 sustaining a displaced left humerus (long bone of the arm) fracture (broken bone), and left untreated for four days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 8 of 14 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 06/05/2018 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 Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on 1/9/18. Resident 1's diagnoses included generalized muscle weakness, diabetes ([DM] high blood sugar), hypertension (high blood pressure), and left-sided hemiparesis (inability to move one side of the body). A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 124/18, indicated the resident had no memory problems, was able to make needs known and understand others. The MDS indicated Resident 1 was assessed as having functional limitation in range of motion of the upper and lower extremities on both sides of the body. The MDS indicated Resident 1 was dependent with bed mobility, transferring, locomotion on and off the unit, and required assistance with eating and personal hygiene. A review of a licensed nursing note, dated 3/1/18, and timed at 9:45 a.m., indicated two certified nursing assistants (CNAs) observed Resident 1, on the same day, with a slight bluish discoloration of the left upper arm during care. The note indicated Resident 1 complained of mild discomfort to the left upper arm with a pain level 1 to 2 out of 10 (pain scale). According to the note, Resident 1's left arm was contracted (permanent condition of shortening and hardening of muscles, tendons, leading to deformity and rigidity of joints) and the resident kept the arm towards the chest area. A review of a licensed nursing note, dated 3/1/18, and timed at 10:30 a.m., indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 9 of 14 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 06/05/2018 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 1's physician was notified of the resident's bluish discoloration of the left upper arm. A review of a physician telephone order, dated 3/1/18, indicated hold left elbow splint for three days and hold range of motion ([ROM] measurement of movement around a joint) to left upper arm for three days for Resident 1. A review of a physician telephone order, dated 3/2/18, indicated to administer Resident 1 Tylenol (pain reliever) 650 milligrams (mg) orally for management of the left shoulder and arm pain, (325 mg -two tablets). A review of a licensed nursing note, dated 3/2/18, and timed at 3 p.m., indicated Resident 1 remained on monitoring for left upper arm skin discoloration. The note indicated the discoloration was subsiding and Tylenol 325 mg was administered for pain management of the left arm as ordered. A review of a licensed nursing note, dated 3/3/18, and timed at 12 p.m., indicated Resident 1 was on continued monitoring for left upper arm skin discoloration and had no complaints of pain. A review of a licensed nursing note, dated 3/3/18, and timed at 10:10 p.m., indicated Resident 1 was being monitored for left upper arm pain and back bruising with slight swelling and mild pain. A review of a licensed nursing note, dated 3/4/18, and timed at 10:15 p.m., indicated Resident 1 was seen and examined by the physician with no new orders. A review of a therapy progress note, dated 3/5/18, and timed at 10 a.m., indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 10 of 14 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 06/05/2018 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 Occupational Therapist ([OT] profession focused on the activities that give daily life meaning, from self-care to leisure to work) 1 assessed Resident 1 at the request of the Director of Nursing (DON) due to Restorative Nursing Assistant 1 (RNA 1) observing redness to the resident's left arm. According to the note, OT 1 recommended an x-ray of Resident 1's left shoulder and humerus (long bone in the arm from the shoulder to the elbow) to rule out the cause of the resident's left upper arm discoloration. A review of a licensed nursing note, dated 3/5/18, and timed at 10:30 a.m., indicated Resident 1 was observed with scattered bruising of the left arm and upper shoulder area. A review of the Situation, Background, Assessment, Recommendation ([SBAR] communication tool used between licensed nurses) communication form, dated 3/5/18, indicated Resident 1's scattered bruising of the left upper arm had gotten worse due to increased discoloration, with increased swelling. The SBAR indicated Resident 1 reported a slightly higher pain level of 5 out of 10 on a pain scale with grimacing (a facial expression usually of disgust, disapproval, or pain). According to the SBAR, Resident 1 was administered routine Tylenol orally and repositioning of the left upper arm. A review of a physician telephone order, dated 3/5/18, and timed at 10:30 a.m., indicated an xray of Resident 1's left shoulder and left humerus. A review of the X-ray results, dated 3/5/18, and timed at 1 p.m., indicated left humerus fracture (broken bone) of the surgical neck, with medial displacement of the distal fragment and medial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 11 of 14 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 06/05/2018 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 apex angulation (malposition of the bone from normal location) and mild soft tissue swelling. A review of a pain assessment note, dated 3/5/18, and timed 7 a.m. to 3 p.m. (day shift), indicated Resident 1 had an acute fracture of surgical neck with complaints of pain 5 out of 10. A review of a licensed nursing note, dated 3/5/18, indicated to transfer Resident 1 to the general acute care hospital (GACH) for further evaluation of the left humerus fracture. During an interview, on 3/15/18 at 10:40 a.m., Resident 1's family member (FM 1) stated, "My family member is paralyzed on the left side from a stroke 20 years ago. The hospital told me she had a humerus fracture on the left side. No one from the facility knows how it happened." On 3/15/18 at 10:54 a.m., during an interview, Resident 1 stated, "I feel fine, my arm hurts a little. No one hurt my arm, I do not know what happened, I just have this thing (sling) to support my arm. I cannot move my arm." On 3/15/18 at 1:06 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated, "She (Resident 1) has a brace on the left side and was receiving ROM on the left side." On 3/15/18 at 1:19 p.m., during an interview, LVN 2 stated, "The CNA reported to me that the resident's left arm and shoulder was bruised. I went with the Registered Nurse (RN) supervisor to look, her (Resident 1) arm was bruised and swollen." On 3/15/18 at 1:35 p.m., during an interview, RN 1 stated, "The resident (Resident 1) has a left flexion contracture. She keeps her left arm FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 12 of 14 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 06/05/2018 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 close to her body. I only saw discoloration, no swelling. I called the physician and the order was to stop ROM and keep sling on left upper arm and watch for increased bruising or swelling for the next three days. The resident complained of pain 2 out of 10 and had bluish discoloration on the anterior and posterior of the arm. The DON was here and made aware." On 3/15/18 at 2:13 p.m., during an interview, CNA 1 stated, "I was cleaning the resident (Resident 1) and saw discoloration on the left arm. I told the charge nurse right away. I did not touch her arm. About three or four days later the bruising got bigger." On 3/20/18 at 11:56 a.m., during a telephone interview, FM 2 stated, "The facility called and told me about the bruise on the left arm. I went to visit two days later and the bruise looked fresh, I told the head nurse to get an X-ray, but if I didn't ask they were not going to get an xray." On 3/22/18 at 2:11 p.m., during a telephone interview, LVN 3 stated, "The family of the resident (Resident 1) was visiting and did request an x-ray for the family member's arm, I told the charge nurse and I'm not sure why she did not document it." A review of the facility's undated policy titled, "Change in Condition," indicated the change in condition signs and symptoms were to assist in guiding the assessment and management of common changes in resident status that can result in acute care transfers. The policy indicated to ensure timely assessments, contacts with primary care providers, and transfers to the acute hospital when indicated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GTZW11 Facility ID: CA940000097 If continuation sheet 13 of 14 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 06/05/2018 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: GTZW11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA940000097 (X5) COMPLETE DATE If continuation sheet 14 of 14