Other·July 26, 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 an Entity Reported Incident (ERI) during an Abbreviated Survey. ERI Number: CA00572350 Representing the Department of Public Health: Evaluator ID: 37393, RN, HFEN The inspection was limited to the specific ERI investigated and does not represent the findings of a full inspection of the facility. There was one deficiency issued for CA00572350

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 07/13/2018 §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 §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's staff failed to follow its policy and 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: XC0M11 Facility ID: CA940000097 If continuation sheet 1 of 6 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 06/26/2018 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 develop a plan of care to address a resident's risk for elopement (to flee or to run away secretly) and provide adequate supervision for one of three sampled residents (Resident 1). Resident 1, who had a high risk for elopement and was deaf (unable to hear), mute (nonverbal), left the facility unsupervised. Resident 1 was found eight (8) and half hours later, 4.2 miles away from the facility at a bus stop by the police. This deficient practice, of the facility not providing Resident 1 adequate supervision resulted in the resident leaving the facility unsupervised. Resident 1, who was deaf and mute, was at risk for injuries and accidents while out of the facility unsupervised. Resident 1 did not receive his evening gastrostomy tube ([GT] a tube inserted surgically through the abdomen for nutrition and hydration directly into the stomach) feeding or medications as prescribed by the physician for over 8 hours. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 8/27/17. Resident 1's diagnoses included deafness and mute, dysphagia (difficulty swallowing) with a gastrostomy tube ([GT] a tube inserted surgically through the abdomen for nutrition and hydration directly into the stomach), dementia (a decline in mental ability severe enough to interfere with daily life and functioning), difficulty in walking, with ataxia (the loss of full control of bodily movements). A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 10/23/17, indicated Resident 1 had memory problems, impaired FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XC0M11 Facility ID: CA940000097 If continuation sheet 2 of 6 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 06/26/2018 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 decision-making, and was unable to make needs known and understand others. According to the MDS, the resident was assessed as being dependent on staff for bed mobility, transferring, locomotion on and off the unit, requiring assistance with eating and personal hygiene. A review of Resident 1's elopement risk assessment, dated 12/15/17, indicated a score of 10. According to the assessment, a total score of 10 or greater was a high risk for elopement, and the prevention protocols should be documented on the resident's care plan. There was no plan of care to address Resident 1's elopement risk. A review of a licensed personnel progress note, dated 2/2/18, and timed at 9 p.m., indicated Certified Nursing Assistant 1 (CNA 1) reported that Resident 1 was not in the dining room. The note indicated that the staff immediately started to search for the resident in his room, around the facility, North and South stations, bathrooms, parking lots, the emergency exits, and the facility's lobby. Resident 1 was nowhere to be found. A review of a licensed personnel progress note, dated 2/2/18, and timed at 9:30 p.m., indicated the staff continued to search for Resident 1 in the outside vicinity at stores, park, nearby streets, while asking passersby if the resident was seen, but was unsuccessful to locate resident. Ongoing search in progress. A review of the licensed personnel progress note, dated 2/2/18 and timed at 10:30 p.m., indicated the resident (Resident 1) was still missing and the staff were unsuccessful in locating the resident at that time. Ongoing search in progress. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XC0M11 Facility ID: CA940000097 If continuation sheet 3 of 6 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 06/26/2018 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 personnel progress note, dated 2/2/18, and timed at 11:15 p.m., indicated the staff called the Police Department to report a missing resident (Resident 1). A review of the licensed personnel progress note, dated 2/2/18 and timed at 11:30 p.m., indicated Resident 1's emergency contact person was called and informed about the resident's elopement. A review of a licensed personnel progress note, dated 2/3/18, and timed at 12:45 a.m., indicated the responding police officer arrived to the facility and obtained a detailed report about Resident 1, which included his description, last location seen, and clothing description. A review of a licensed personnel note, dated 2/3/18, and timed at 1:15 a.m., indicated the staff received a call from police officer indicating the resident's search will be placed in system and they will send a search team to continue to search for Resident 1. On 2/6/18 at 9:20 a.m., during an interview, the Social Services director (SSD) stated, "We use a communication board with pictures to communicate with the resident (Resident 1). He can read very well, but is deaf and mute. We also write questions on a dry erase board for him to read." On 2/6/18 at 9:59 a.m., during an interview, the Administrator (ADM) stated, "There are three exits in the facility and the front door is locked at 6 p.m. We have an exit that leads to the alley and the other exit is on the smoking patio." On 2/6/18 at 10:10 a.m., during an interview, the Maintenance assistant (MTA) stated, "The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XC0M11 Facility ID: CA940000097 If continuation sheet 4 of 6 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 06/26/2018 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 door to the alley has no alarm and is always unlocked, the other doors have loud alarms." On 2/6/18 at 10:44 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) in the presence of the SSD asked Resident 1, using the dry erase board what exit he used to elope from the facility. Resident 1 replied by pointing to the exit in the North Nursing Station, that leads to the alley. On 2/6/18 at 3:16 p.m., during an interview, LVN 2 stated, "The resident has a feeding tube feeding that supposed to start at 8 p.m. and he refused it. I came back at 9 p.m. to attempt to start the resident's GT feeding, but he (Resident 1) was nowhere to be found. I told the charge nurse (LVN 3) that the resident was gone. He probably left out of the back door, which leads to the alley and the parking lot. There is no alarm on the back door." On 2/6/18 at 4:09 p.m., during an interview, LVN 3 stated, "It was reported to me by a certified nursing assistant (CNA) that the resident was missing. I walked around the neighborhood and when I came back; I called the administrator, the Director of Nursing (DON) and the Police Department. The resident was found a few hours later." A review of a missing person report written by the police, dated 2/2/18 and timed at 11:16 p.m., indicated a missing person (Resident 1) was last seen between the hours of 9 p.m. and 10 p.m. on 2/2/18, the report indicated it was critical to find the resident due to multiple medical conditions. The report also indicated "Unknown destination." A review of the Police Missing Report, dated 2/3/18 and timed at 6:44 a.m., indicated Resident 1 was found at a bus stop 4.2 miles FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XC0M11 Facility ID: CA940000097 If continuation sheet 5 of 6 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 06/26/2018 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 away from the facility and was transferred back to the facility and released to the head nurse. A review the facility's policy titled, "Wandering /exit seeking behavior," dated 4/2017, indicated the facility will evaluate residents for wandering and/or exit seeking behavior and implement appropriate interventions as indicated via the evaluation process. The nurse, interdisciplinary team (IDT) or designee develops a care plan for residents with a potential for wandering and/exit seeking behavior. The care plan should address the resident's wandering behavior, potential to exit the facility and/or actual episodes of elopement and the measures taken to manage these behaviors. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XC0M11 Facility ID: CA940000097 If continuation sheet 6 of 6