Beachside Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen dishwasher temperature gauge was functioning properly. This failure had the potential to expose residents to dishes washed at unsafe temperatures, which could promote bacterial growth and increase the risk of foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins )

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor range of motion (ROM-the full movement potential of a joint) for four of nine sampled residents (Residents 58, 15, 38, and 52) who had or were at risk for limited ROM and mobility. The facility failed to:1. Ensure Resident 58 received two quarterly Joint Mobility Screens (JMS-a brief assessment of ROM in both arms and legs) in 5/2025 and 8/2025.2. Ensure Resident 15 received a quarterly JMS in 7/ 2025.3. Ensure Resident 38 received a quarterly JMS in 7/2025.4. Ensure Resident 52 received a quarterly JMS in 5/2025. These failures had the potential for Residents 58, 15, 38, and 52 to develop further ROM limitations in the arms and legs due to the lack of monitoring.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 113) was assessed, and that the physician was notified when Resident 113 experienced a significant change of condition (COC- a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff) of low blood pressure. This failure resulted in Resident 113's low blood pressure going unnoticed by licensed staff, placing the resident at risk for adverse outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 18) by not addressing Resident 18's toenail fungus (a fungal infection below the surface of the nail) in the care plan. This deficient practice had the potential to negatively impact the delivery of necessary care and services for Resident 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) process for one of four sampled residents (Resident 106), when Resident 106 reported pain in his left shoulder. This failure had the potential for Resident 106's pain to remain uncontrolled, affecting comfort and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Residents 84 and 113) were free from significant medication errors. The facility failed to:1. Ensure Resident 84's lidocaine patch (a medication used for localized pain relief) was removed at the scheduled time. This failure had the potential to expose Resident 84 to prolonged medication absorption and increase the risk of adverse reactions, which could lead to a decline in the resident's ability to perform activities of daily living.2. Ensure Resident 113 did not receive medication for heart failure when the resident's systolic blood pressure was less than 110 millimeters per mercury (mmHg-unit of pressure), as required by the physician's order to hold the medication if systolic blood pressure was below 110 mmHg. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the two dryers' gas hoses connected to the gas line were intact and free from leaks. This failure had the potential to increase the risk of fire or carbon monoxide exposure to residents which could result in injury or harm.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy when they did not report an unusual occurrence of an acute new distal femur fracture (a break in the lower part of the thighbone, near the knee joint) of unknown cause to the State Survey Agency (California Department of Public Health - CDPH) within 24 hours of the occurrence, for one of the three sampled residents (Resident 1). This failure had the potential for resident harm and/or death, due to CDPH ' s inability to promptly investigate the possibility of resident abuse in the facility. This delayed CDPH response to ensure Resident 1 was safe and free from possible abuse and/or mistreatment in the facility and had the potential for other unusual occurrences to go unreported.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen staff including the dietary supervisor assistant (DSA) and dietary aide (DA 1) were competent regarding their food thawing policies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope [a scientific magnifying device]) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated [something that has been made impure or unfit for use by contact with something harmful] food for 99 out 106 total residents in the facility by not ensuring: a. Cottage cheese in the reach-in refrigerator was not past the use by date. b. The temperature log for the walk-in refrigerator was filled out twice daily c. Food such as raw chicken and frozen waffles were not thawed and then returned to the freezer. d. Proper thawing techniques by not having running water over thawing chicken in the sink. e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the clinical records were complete and accurately documented by: a. failing to ensure the documentation for one out of six sampled residents (Resident 84) related to Resident 84's intravenous (IV, administered into a vein) access and IV fluids (liquids that are injected into a vein to prevent or treat dehydration [occurs when the body loses more fluids than it takes in]) was accurate. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures by failing to: A. Ensure Resident 260's visitor was wearing Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and Licensed Vocational Nurse (LVN) 2 and LVN 3 were doffing (removing PPE in a way that avoids self-contamination) PPE properly without self-contamination after caring for Resident 260 who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms). B. Ensure LVN 1, LVN 4, and Certified Nurse Assistant (CNA) 1 were wearing proper PPE during the care of Resident 8 who was on EBP. C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of five sampled residents (Resident 8). This failure had the potential to prevent Resident 8 from receiving the necessary care and services timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor range of motion ([ROM] full movement potential of a joint [where two bones meet]) in both legs for one of eight sampled residents (Resident 49) with limited range of motion and mobility (ability to move) by failing to perform an annual Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in both arms and both legs) on 4/18/2024 in accordance with the facility's policy titled, Resident Mobility and Range of Motion. This failure had the potential for Resident 49 to develop further ROM limitations in both legs due to the lack of monitoring for potentially 21 months from Resident 49's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge on [DATE] to 4/2025 (next annual JMS).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide prompt dental services after dentures were lost on 9/10/24 and provide documentation of what they did to ensure resident could still eat and drink adequately while awaiting dental services for one of two sample residents (Resident 30). This deficient practice resulted in Resident 30 not being able to eat the mechanical soft diet without the dentures until replacement was delivered on 10/31/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 30) received food according to her preferences. This deficient practice resulted in Resident 30 not eating her preferred diet potentially resulting in decrease meal intake, weight loss, and malnutrition (lack of proper nutrition, caused by not eating enough).

Inspectors wroteBased on interview and record, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone). This deficient practice resulted in the inability of CDPH to investigate Resident 1 ' s injury of femur fracture in a timely manner and had the potential for facts related to the injury to be forgotten by staff.

Inspectors wroteBased on interview and record, the facility failed to ensure an injury of unknown origin was investigated for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone) and the cause of the fracture was unknown to the resident and staff. This deficient practice resulted in the inability of the facility to determine what might have been the cause of Resident 1 ' s injury and had the potential to recur.

Inspectors wroteBased on interview and record review, the facility failed to update and document belongings brought by the family on the inventory list for three of four sampled residents (Resident 1, 4, 5). This failure resulted in residents losing items due to not having them written down on the inventory list.

Inspectors wroteBased on observation, interview, and record review, the facility failed to handle and store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food) for 99 out of 99 total residents in the facility by failure to: 1. Ensure enriched Farina hot wheat cereal have a received date label. 2 Ensure Dietary Aide (DA) 1, DA 2, DA 3, DA 4 and [NAME] 2 did hand hygiene (hand washing ) and don gloves when handling food during the tray line (a process of preparing and setting food for the residents in the facility). 3 Ensure ice machine maker door lining was kept clean. 4 Ensure freezer thermometer was calibrated and in working condition. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a dignity or privacy bag (a urinary drainage bag holder that restores the dignity of catheterized [insertion of a tube into the bladder to allow urine to drain for collection] residents by covering urinary drainage bags from the public view) for one of 20 sampled residents (Resident 307) indwelling catheter (a tube that drains urine from the body into a bag outside the body). This failure had the potential to result in Resident 307's low self-esteem and privacy being violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled resident (Resident 256) responsible party (RP) was notified when the hemoglobin (a red protein responsible for transporting oxygen in the blood) dropped significantly to 7.3 grams/deciliter (g/dcl-normal levels 11.6-15) This failure violated the Resident 256's rights of notification of responsible parties of the care services provided and had the potential to result in a lack of proper care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) regarding the use of Depakote (a medication used to treat mood problems) to treat a behavioral problem of sudden outbursts of anger in one of five residents sampled for unnecessary medications (Resident 74.) This failure to develop and implement a care plan with measurable objectives for the use of Depakote may result in not meeting Resident 74's medical, nursing, and mental and psychosocial needs to maintain or attain Resident 74's highest practicable, physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility staff failed to ensure resident received radiation treatments (cancer treatment that uses radiation (usually high-powered X-rays) to kill cancer cells.) for basal cell carcinoma (type of skin cancer) of the left eye for one of seven sampled residents (Resident 48) by: 1. Failing to send Resident 48 to the correct outpatient department for a scheduled radiation treatment on 11/22/2023. 2. Failing to provide transportation for an outpatient scheduled radiation treatment on 11/27/2023. These failures resulted in a delay of services/treatments and the potential for Resident 48 to be exposed to radiotoxicity for back-to-back radiation treatments.

Inspectors wroteBased on interview and record review, the facility failed to act on one recommendation from the consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from 10/5/23 regarding lowering of the dose of esomeprazole (a medication used to treat stomach acid problems) from twice daily to once daily in one of five residents sampled for unnecessary medications (Resident 74.) This failure of failing to respond to recommendations from the consultant pharmacist could have resulted in Resident 74 receiving a higher than necessary dose of esomeprazole possibly resulting in medication side effects (a secondary, typically undesirable effect of a drug or medical treatment).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one expired fluticasone/salmeterol (a medication used to treat breathing problems) inhaler for Resident 22, was removed from the medication cart in one of two inspected medication carts (Medication Cart 2.) This failure could have resulted in Resident 22 experiencing preventable episodes of shortness of breath and troubled breathing possibly leading to hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor food preference of one of two sampled residents (Resident 356) by ensuring vegetables are not overcooked. This failure had the potential for Resident 356 to not receive their nutritional needs and food preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures on two of six sampled residents (Resident 27 and Resident 43) when Certified Nursing Assistant 3 placed a plastic bag with soiled linens on the fall mat (cushioning pad placed on the floor along the side of the bed that can reduce injury due to fall) of Resident 43 while providing care to the residents. This failure had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for infection.

Inspectors wroteBased on interview and record review the facility failed to implement their antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) on one of two sampled residents (Resident 26) by prescribing an antibiotic without meeting the criteria of their protocol (checklist or guide to initiate antibiotic) for urinary tract infection([UTI] infection in the urine). This failure had the potential to put Resident 26 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic.

Inspectors wroteBased on interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was answered in a timely manner and helped in toileting by Certified Nursing Assistant (CNA) 4. This failure had the potential to negatively affect Resident 1's physical comfort and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Polymerase Chain Reaction ([PCR] a test used to detect the smallest amount of COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath [SOB]) test was conducted to confirm negative COVID-19 test results obtained via a Point of Care Antigen test ([Antigen] a rapid test that quickly detects the presence or absence of an antigen [a foreign substance] but is less accurate than a PCR test) test, when one out of two sampled residents (Residents 1) continued to exhibit signs and symptoms (s/s) of COVID-19, after his Antigen COVID-19 test results were negative. [...]