Other·February 28, 2020

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 Standard Survey. Complaint number: CA00665657 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 16282 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. One deficiency was issued for CA00665657

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 02/27/2020 §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 failed to implement a plan of care and follow the physician's order for one of three 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: HSXE11 Facility ID: CA940000097 If continuation sheet 1 of 7 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 01/31/2020 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 sampled residents (Resident 1). Resident 1, who was a high risk for falls, had a physician order for a bed alarm (used to alert staff when a resident attempted to get out of bed) which was not utilized. This deficient practice resulted in Resident 1 having two falls within six (6) days, with the last fall resulting in injury. Findings: A review of Resident 1's Admission Record indicated Resident 1 was originally admitted on 11/11/19. Resident 1's diagnoses included muscle weakness, with leg and back pain and other lack of coordination. A review of Resident 1's Physician's Orders, dated 11/11/19 indicated physical therapy evaluation and treatment as indicated. A review of Resident 1's Nursing Assessment, dated 11/11/19 indicted Resident 1 was alert and oriented to person, place, time and situation, spoke English and required moderate assistance with bed mobility and transfers. A review of Resident 1's Fall Risk Assessment, dated 11/11/19 indicated the resident was high risk for potential falls (total score of 15). A review of Resident 1's care plan titled, "High Risk for Falls related to History of Arthritis, Poor safety awareness, sensory impairment and intermittent confusion," dated 11/11/19, indicated the following staff's approach plan: -Implement fall precautions; keep call light within reach and answer promptly, keep bed in low position A review of the plan of care dated 11/11/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HSXE11 Facility ID: CA940000097 If continuation sheet 2 of 7 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 01/31/2020 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 High Risk for fractures/injury related to history of falls/ sliding from bed indicated the following interventions: - Monitor and anticipate needs - Place call light within reach - Assist with ADL's as needed - bed in the lowest position - frequent visual monitoring - Physical therapy (PT) and Occupational therapy (OT) evaluation and treatment A review of Resident 1's PT Evaluation and Plan of Treatment, dated 11/12/19, indicated the reason for referral was due to Resident 1's decline in functional mobility, strength, coordination, functional capacity/ cardiopulmonary skills, activities of daily living (ADL) participation and inability to ambulate. The form indicated Resident 1 had precautions which included a fall risk and currently used a wheelchair for locomotion. The form indicated Resident 1 felt unsteady when standing and walking with no history of falls in the past year. The risk factors included falls. On 11/18/19 nursing was given training using pillow wedge in order to increase safety and reduce risk of further medical complications. A review of Resident 1's Minimum Data Set (MDS), resident assessment and carescreening tool, dated 11/15/19, indicated the resident required total dependence for bed mobility and transfers with two plus persons physical assist. The MDS indicated Resident 1's functional limitation in range of motion included impairments of the lower extremities on one side. Resident 1 was moderately impaired in cognitive (thought process) skills for daily decision making was able to be understood and usually able to understand others. The MDS indicated Resident 1 had no behaviors, and was incontinent of bowel and bladder with no history of falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HSXE11 Facility ID: CA940000097 If continuation sheet 3 of 7 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 01/31/2020 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 Change of Condition (COC) Situation Background Assessment and Recommendation ([SBAR] communication tool) form, dated 11/22/19 indicated a 9 p.m., Resident 1 was noted on the floor, in a sitting position. The COC SBAR indicated Resident 1 was alert and oriented to person, verbally responsive in stable condition, with no complaints of pain. A bump was noted on the posterior (back) aspect of the resident's head. A complete X-ray of the skull was ordered. The care plan interventions included to monitor Resident 1 at all times, and frequent visual checks with call light within reach. A review the Licensed Personnel Progress Notes, indicated on 11/23/19, at 3:15 p.m., the skull X-ray results indicated no displaced fracture (broken bone) seen. The note indicated at 10 p.m., safety precautions were in place with the bed in low position and floor mats provided. The note indicated the resident's Care Plan "Risk for Falls," was updated on 11/23/19 for PT/OT evaluation and treatment only as an additional approach plan. A review of the Fall Risk Meeting Assessment, dated 11/25/19 indicated Resident 1 had intermittent confusion. The new orders noted included bed alarm, lowest bed position and floor mats for safety. The assessment indicated the continuation of the care plan for "Risk for Falls" dated 11/25/19, indicated bed alarm pad to alert staff when resident needed assistance and monitor placement every shift, lowest bed position for safety and monitor placement every shift, and bilateral floor mats for safety and monitor placement every shift. A review of Resident 1's Status Post Fall Assessment Rehab Services note, dated 11/25/19 indicated Resident 1 was very FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HSXE11 Facility ID: CA940000097 If continuation sheet 4 of 7 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 01/31/2020 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 impulsive, and confused with poor safety. A review of the Licensed Personnel Progress Notes on 11/27/19 at 2:00 a.m., the resident was noted with behaviors, confused and noncomplaint. The resident was removing the colostomy bag and continuing to want to get out of bed. A review of the Change of Condition SBARActual or Suspected Fall indicated on 11/28/19 1:15 a.m., Resident 1 had an unwitnessed from the bed in his room. There was no additional circumstances: of alarm activated/sounding or alarm failure or device removal. The bed was in lowest position and there was no bed rails in use. The resident was alert and unable to communicated what occurred, he was noted with a laceration on the right forehead and redness on the hip. The resident was transferred to the general acute care hospital (GACH). A review of Resident 1's history and physical from the GACH, dated 11/28/19 indicated Resident 1 had a history of multiple falls and rolled out of bed and fell approximately two (2) feet onto the floor. The GACH emergency room records indicated Resident 1 had no evidence of acute intracranial bleeding (bleeding in the brain) or skull fracture, the resident was admitted due to the fall and tachycardia. On 12/13/19 at 2:30 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated there were no side rails on Resident 1's bed and he would continuously attempt to get up and stand. LVN1 stated after Resident 1 fell the second time (11/28/19), floor mats were placed on the floor next to the Resident 1's bed. On 1/30/20 at 3 p.m., CNA 1 stated Resident 1 tried to get out of bed a lots of times. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HSXE11 Facility ID: CA940000097 If continuation sheet 5 of 7 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 01/31/2020 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 On 1/30/20 at 3:30 p.m., during an interview, LVN2 stated on 11/22/19 he was passing medications and CNA reported to him Resident 1 had a fall. LVN 2 stated Resident 1 was found on the side of the bed on the floor in a sitting position with a bump on the back of his head. LVN 2 stated at that time, Resident 1's bed was not in in low position. LVN2 stated the nurse's interventions included to monitor, do neurological checks (assessment of mental status) and visual checks and keep the call light within reach. On 1/30/20 at 4:10 p.m., during an interview, CNA 2 stated Resident 1 would be jittery (inability to stop moving) and would slide down in the bed. CNA 2 stated Resident 1's bed was keep in the lowest position and had a low air loss mattress ([LAL] a mattress used to prevent pressure sores) in place and no side rails. CNA2 stated on 11/28/19, while she was Resident 1's sitter to prevent her from falling, she was sitting at the door of Resident 1's room and she turned to look and Resident 1 was on the floor. CNA 2 was asked if she heard any noise (such as a bed alarm), and she stated she did not here any noise when Resident 1 fell. On 1/31/20 at 12:55 p.m., during an interview, LVN 3 stated Resident 1 was very fidgety (restless, uneasy), had a low air loss ([LAL] used to relieve pressure) mattress with floor mats and pillows to keep resident aligned in bed. LVN3 stated there were no bed side rails or tab alarm in place, because Resident 1 moved too much and the alarm would sound continuously. LVN 3 stated after Resident 1 was found on the floor after a fall on 11/22/19 a sitter was placed due to Resident 1 being fidgety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HSXE11 Facility ID: CA940000097 If continuation sheet 6 of 7 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 01/31/2020 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 policy titled "Falling Star Program," revised on 6/13, indicated the purpose of the policy was to identify residents who have had two or more previous falls; try to prevent additional falls; and attempt to increase supervision for residents identified at high risk for falls, when the resident has had two or more previous falls since admission to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HSXE11 Facility ID: CA940000097 If continuation sheet 7 of 7