Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beachside Nursing Center during CMS and state inspections, most recent first.
A resident with a Stage 3 sacrococcygeal pressure injury requiring daily wound care did not have Enhanced Barrier Precautions (EBP) signage or a PPE cart at the room entrance, despite facility policy identifying residents with chronic wounds as candidates for EBP. During an observed wound care procedure, an LVN and a CNA performed and assisted with care without wearing gowns, contrary to policy requiring gowns and gloves for high-contact tasks. Both staff members acknowledged not using gowns, citing the absence of EBP signage and their belief that gowns were only needed for certain types of wounds, while the infection prevention leader later confirmed that EBP signage, PPE availability, and gown use should have been in place.
A resident admitted with a documented diagnosis of post-status cardiac pacemaker placement did not have a corresponding problem or interventions included in the care plan. Review of the care plan for the relevant period showed no entry addressing the pacemaker, and the DON confirmed during interview and record review that the device and its related needs were not care planned, creating a risk that appropriate treatment and services for the pacemaker would not be provided.
Surveyors found that the facility failed to maintain complete and accurate clinical records for several residents. For one resident who died, staff described detailed assessments and observations around the time of death, but these were not documented in the chart, nor were the names and titles of staff involved. Another resident with dysphagia and a GT was ordered NPO, yet physician orders and the MAR listed several medications as given by mouth instead of via GT, despite staff stating all medications were administered through the tube. A third resident’s treatment and monitoring orders for antifungal cream and a low air loss mattress had multiple PM shifts on the TAR left blank, with no initials or codes to show whether care was provided. For a discharged resident, the IDT care plan review form was missing numerous required entries, including participation, team member names, advance directive details, discharge planning information, and signatures or indications of agreement, and there was no set of vital signs documented at the time of discharge even though the discharge note stated the resident left with stable vital signs.
Expired and improperly dated food items were found in kitchen storage areas during a surveyor tour. A Diet Lead and surveyor observed sliced cheese, instant mashed potatoes, celery, red bell peppers, cabbage, and an open sliced ham package past their use-by dates or dated inconsistently with facility P&P, and the Diet Lead verified the findings. The RD was later informed and acknowledged the issue.
Incomplete informed consent for psychotropic medications: A resident with decision-making capacity was ordered Abilify and sertraline for depression with specific manifested behaviors, but the consent forms listed anxiety instead, did not include the behavior manifestations, and lacked the prescriber's signature. RN verified the consents did not match the physician orders, and the resident stated she had not been told the meds were being given for depression.
Failure to provide privacy during medication administration: A resident with moderately impaired cognition was observed receiving medications in the hallway while other residents and staff passed by. The LVN verified privacy was not provided, and the resident stated she preferred to receive medications inside her room.
Unsafe Nightstand in Resident Room: A resident's nightstand was observed with a drawer that would not fully close and warped wood on the side nearest the bed, while a bedside commode was placed in front of it. The resident, who had decision-making capacity, said the broken furniture could tear her skin or bump her head, and a family member expressed concern about possible injury. An RN verified the condition during observation.
The facility failed to keep two residents’ care plans current when their needs changed. One resident had significant unplanned weight loss and physician-ordered diet changes, but the nutrition care plan was not revised to reflect the weight loss event. Another resident was placed on contact isolation for shingles and ordered to remain in a single room, but the activity care plan was not updated to address room-based activities or the resident’s inability to attend group activities. The DON and Activity Director acknowledged the missing revisions.
A resident with multiple cardiac and anticoagulant medications had an unwitnessed fall, but the chart did not show a post-fall physical assessment, post-fall VS, or neuro checks, and staff verified the documented VS were taken before the fall. The resident also received sacubitril-valsartan without documented BP and HR checks despite hold parameters, and the fall risk tool was completed inaccurately. In a separate issue, a resident ordered Magic Cup with meals did not receive the supplement because the kitchen had run out.
Failure to monitor and document urinary output for a resident with an indwelling urinary catheter. The resident had a catheter ordered for urinary retention, and the care plan included monitoring intake and output, but the record showed no documented output. CNA staff said they emptied the drainage bag and reported the amount to the LVN, while the LVN, RN, and DON acknowledged that output was not being monitored and documented as reflected in the care plan.
A resident with nutritional risk experienced significant weight loss, dropping from 130 lbs. to 125 lbs. and then to 111 lbs. The record did not show that the physician was notified after the initial 5-lb. loss, and the RD’s nutrition IDT update was left incomplete after the larger loss. Staff interviews confirmed the weight loss should have triggered physician notification and an IDT review, but documentation was missing and the DON verified no IDT meeting or change-of-condition document was completed for the earlier weight loss.
Respiratory care was not properly managed for three residents. One resident was observed using oxygen without a documented order and later received oxygen at 3 L/min when the order was for 2 L/min. The resident’s nebulizer mask and tubing were also not labeled or stored correctly. Two other residents had nebulizer equipment left exposed on bedside furniture instead of being stored in labeled bags, and one resident’s chart did not show an order for nebulizer treatment.
A facility failed to provide ordered pharmaceutical services for two residents. An LVN did not administer a prescribed probiotic supplement to one resident during med pass, and for another resident with HTN, staff did not obtain or document BP and HR before holding ordered amlodipine-olmesartan and metoprolol succinate based on hold parameters. The DON and other nursing staff verified the findings.
Medication storage and labeling were not properly maintained for two residents’ controlled-drug bubble packs, one unlabeled insulin pen, and a topical cream left unattended at a resident’s bedside. An LVN verified open blister packs for hydrocodone-acetaminophen and oxycodone in a med cart, and another unlabeled Lantus pen lacked the resident’s name, directions, physician, and pharmacy information. A resident with no decision-making capacity also had Calmoseptine cream left on the bedside table without a documented order, and staff confirmed it had been applied earlier that morning.
A resident's wound vacuum machine and connector tubing were observed stored on the floor beside the bed. An LVN confirmed the equipment and tubing should not be on the floor for infection control, and the resident had orders for a left lower leg wound vacuum with continuous suction and related wound care.
Failure to provide accurate COVID-19 vaccine education and documentation for two residents. One resident was cognitively intact and had a past-due seasonal COVID-19 vaccine, but the consent form incorrectly stated the resident was up to date and declined because of prior vaccination. Another resident had no record of ever receiving a COVID-19 vaccine, yet the RP declined vaccination on the basis that the resident was previously vaccinated and up to date.
Surveyors identified multiple failures in food safety and sanitation, including improperly stored and unlabeled food items, unsanitary kitchen equipment, and maintenance issues such as a missing tile and rusted surfaces. These deficiencies were confirmed by staff and affected nearly all residents receiving dietary services.
Two residents did not receive care and services according to physician orders and facility policy. One resident with memory impairment was repeatedly served meals in bed despite an order to be up in a chair, and staff confirmed the order was not followed. Another cognitively impaired resident wore a wander-monitoring bracelet for elopement prevention, but there was no physician order or care plan in place for its use, as confirmed by staff and record review.
Three residents experienced significant unplanned weight loss due to the facility's failure to follow RD recommendations, notify physicians and representatives, and update care plans. One resident's severe weight loss was not communicated to the physician, another's nutritional status was not reassessed or addressed by the IDT, and a third resident's meal refusals and intake were not properly documented or care planned. The DON and staff confirmed these deficiencies and missing documentation.
A resident receiving enteral feeding via gastrostomy tube did not have tube placement verified prior to the start of feeding, as required by facility policy and physician orders. An RN initiated the feeding without performing the necessary placement check, and later confirmed this omission. The DON acknowledged the deficiency.
Two residents did not receive proper respiratory care as required by physician orders and facility policy. One resident's oxygen was not administered as ordered, with the nasal cannula disconnected and oxygen saturation below the target level until corrected by staff. Another resident's nasal cannula tubing was not dated and lacked a storage bag, contrary to policy, with staff confirming these omissions.
A nurse failed to follow physician orders during medication administration for two residents, resulting in a medication error rate of 7.41%. One resident received metformin without food, contrary to the order to administer with meals, and another was given Advil for severe pain when it was only prescribed for mild to moderate pain. Both residents were cognitively intact, and the errors were confirmed by the nurse.
Surveyors found that medication carts and the medication storage room were not maintained in a clean and sanitary manner, with expired medications not disposed of and oral, rectal, and external medications stored together. Nursing staff and the DON acknowledged these deficiencies, which were not in accordance with facility policy.
Staff did not follow recipes or physician diet orders, resulting in residents receiving incorrect food textures and portion sizes. Some residents were served chopped instead of regular textured diets due to insufficient food preparation, and others received incorrect portion sizes because meal cards were not properly checked. These issues were confirmed by staff and administration.
The facility did not ensure complete and accurate medical record documentation for two residents, including missing documentation of advance directive discussions on a POLST form for a resident with moderate cognitive impairment, and lack of recorded monitoring for a peripheral IV site during antibiotic therapy for another resident. These deficiencies were confirmed by facility staff.
A resident receiving hospice care did not have the hospice care team included in an IDT meeting following a significant change in condition, despite facility policy and hospice contract requirements for collaborative care planning. Facility staff confirmed the omission and acknowledged the need for hospice participation to ensure coordinated care.
Staff failed to follow infection control protocols by not performing hand hygiene before and after resident contact, during medication administration, and when moving between residents. An OTA and two LVNs were observed not washing hands or changing gloves as required, despite facility policies mandating these practices to prevent infection transmission.
Essential kitchen equipment, including the ice machine and low temperature dishwasher, was not maintained in a clean and safe condition, with observed residue, missing parts, and improper chlorine levels. Additionally, required temperature monitoring of the residents' dining room refrigerator was not consistently performed or documented according to facility policy.
A resident was not treated with dignity during a Foley catheter removal as multiple staff were present without permission, including male staff, causing the resident distress. Additionally, the resident's medications were administered late, affecting her ability to participate in physical therapy. The DON acknowledged these deficiencies.
A resident with multiple health conditions did not receive her scheduled 0900 medications until 1030, contrary to the facility's policy of administering medications within one hour of the prescribed time. This delay was confirmed by the resident, LVN, and through a review of the MAR and Medication Admin Audit Report.
Failure to Implement Enhanced Barrier Precautions and PPE Use During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policies related to Enhanced Barrier Precautions (EBP) for a resident with a significant pressure injury. The facility’s infection prevention policy identified residents with chronic wounds as candidates for EBP and required gowns and gloves for high-contact care tasks. Resident 3 was cognitively intact and had a Stage 3 pressure injury to the sacrococcyx extending to both buttocks, with a physician’s order for daily wound care including cleansing, application of Venelex ointment, and dressing with foam and dry dressing. During observation on 4/29/26, there was no EBP signage or PPE cart at the entrance to this resident’s room. LVN 1, who acknowledged the resident’s Stage 3 pressure injury, stated there was no EBP signage because the resident had no chronic wound or catheter and indicated that the admission nurse was responsible for placing EBP signage. During the observed wound care for this resident, LVN 1 and CNA 1 did not wear gowns while performing and assisting with the wound care procedure. LVN 1 acknowledged not wearing a gown and stated that gowns were only needed if a resident had a chronic wound, defining a chronic wound as one that was non-healing or worsening. CNA 1 also confirmed not wearing a gown and explained that she used a gown only when EBP signage and a PPE cart were present at the resident’s door, which were absent in this case. The Director of Staff Development/Infection Preventionist later acknowledged that EBP signage and a PPE cart should have been present for this resident and that staff should have worn gowns during the wound care due to the potential for body fluid exposure. The DON was informed of and acknowledged these findings.
Failure to Care Plan for Resident with Cardiac Pacemaker
Penalty
Summary
The facility failed to develop and implement a care plan that reflected an individual resident’s needs related to a cardiac pacemaker. A resident was admitted with a diagnosis of post-status cardiac pacemaker placement, as documented in the acute care hospitalist history and physical examination dated 3/25/26. Review of the resident’s Care Plan Report covering 3/29–4/1/26 showed no care plan problem was initiated to address the presence and management of the pacemaker. During a concurrent interview and closed medical record review on 4/16/26, the DON verified that the care plan did not include the resident’s pacemaker, resulting in a failure to ensure the care plan addressed this specific medical device and associated needs. This failure posed the risk of the resident not receiving the appropriate treatment and services related to the pacemaker.
Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with its own policies and accepted professional standards for multiple residents, including one who died in the facility and others with active and closed records. For one deceased resident, the record contained only brief progress notes indicating the time of death, confirmation by two licensed nurses, notification of family and administration, and completion of postmortem care. The record did not include documentation of the detailed observations, assessments, vital signs, interventions, or changes in condition surrounding the resident’s death, nor did it identify the names and titles of staff who performed these assessments and interventions. In interview, the LVN assigned to the resident at the time of death described specific assessment actions she took when notified the resident was unresponsive, including checking for a carotid pulse, observing for respirations, and attempting to obtain an oxygen saturation reading, and confirmed that all such observations and staff identities should have been documented but were not. The DON also verified that these elements should have been recorded to provide an accurate and complete account of the resident’s condition. For another resident with dysphagia and a gastrostomy tube (GT) who was ordered NPO, the physician’s orders in the medical record specified that several medications (famotidine, ferrous sulfate, and acetaminophen) were to be administered by mouth. The MAR for the month showed these medications were documented as given via the oral route on multiple occasions. In interview, an LVN stated that this resident was NPO and received all medications via GT, and acknowledged that the ordered route should have been changed to reflect the actual route of administration. The DON was informed and acknowledged that the orders and documentation did not accurately reflect the care being provided. For a third resident, the facility failed to document wound treatment and monitoring as ordered. The physician’s orders included application of antifungal cream 2% to the perineal area every shift and monitoring of a low air loss mattress every shift. Review of the TAR showed multiple PM shifts on which there were no nurse initials or codes to indicate whether the antifungal treatment or mattress monitoring had been completed or, if not, why they were not completed. An LVN reviewed the record and verified these blanks. The Administrator and DON were informed and acknowledged these missing entries. For another discharged resident, the facility failed to complete and accurately document the IDT Care Plan Review and to record vital signs at the time of discharge as required by policy. The IDT Care Plan Review form for this resident’s baseline care plan meeting was missing multiple required elements, including whether the resident participated in care plan development, any explanation if the resident did not participate, the names of social services, activities, and attending physician, verification of admission record information, documentation of advance directive choices, additional comments, the social services plan of care, the summary of the discharge plan, and documentation that the resident or representative had been notified of their rights and agreed with the plan of care. It also lacked documentation of whether the physician or healthcare practitioner participated in and agreed with the care plan review. The SSD and DON both stated they attended the IDT meeting but could not recall details and verified the missing information on the form. Additionally, although the record contained earlier vital signs and a discharge note stating the resident was discharged with stable vital signs, there was no documented set of vital signs obtained just prior to discharge to show the resident’s medical status at that time. An RN confirmed that vital signs should have been taken at discharge, and the DON stated that the expectation was for nurses to obtain vital signs just prior to discharge.
Expired Food Items Found in Kitchen Storage Areas
Penalty
Summary
Food safety guidelines related to food storage were not followed in the kitchen. During an initial tour of the kitchen on 2/22/26, the Diet Lead and surveyor observed a container of four packs of sliced cheese in Reach-in Refrigerator 1 with a use by date of 2/20/26. In the dry storage area, a can of instant mashed potatoes was observed with a date of 9/19/25 on the can and a delivery date of 12/2/25. The Diet Lead verified these findings and removed the items. In Reach-in Refrigerator 2 by the handwashing station, surveyors observed a large bin of celery with a use by date of 2/20/26, a large bin containing ten red bell peppers and one cabbage with a use by date of 2/20/26, and a small container of an open sliced ham package with a used by date of 2/20/26. The Diet Lead verified these findings and removed the items from the refrigerator. On 2/24/26, the RD was informed and acknowledged the findings. The facility's policy titled Labeling and Dating of Foods stated that food items in the storeroom, refrigerator, and freezer must be labeled and dated for food safety or product rotation, and that the use by date is the absolute date the food must be consumed or discarded.
Incomplete Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Resident 80 was fully informed about the use of psychotropic medications and that the informed consent documents were complete for Abilify and sertraline. The resident was admitted with a history showing capacity to understand and make decisions. Physician orders dated 2/22/26 directed Abilify 2.5 mg at bedtime for depression as manifested by verbalizations of feeling hopeless, and sertraline hydrochloride 100 mg in the afternoon for depression as manifested by verbalizations of feeling sad with dinner. The MAR showed both medications were administered on 2/22/26. Review of the psychotherapeutic drug informed consent forms showed Resident 80 signed consent for both medications, but each form listed anxiety as the indication instead of the ordered diagnosis of depression, did not include the behavior manifestations for use of the medications, and did not contain the prescriber's signature. During interview and record review, RN 1 verified there were no informed consents to administer Abilify and sertraline as ordered. Resident 80 stated she had previously taken both medications for anxiety before admission and was not aware the facility was administering them for treatment of depression.
Failure to Provide Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy was provided for Resident 4 during medication administration. Resident 4 was admitted and later readmitted to the facility, and the annual MDS assessment showed a BIMS score of 10, indicating moderately impaired cognition. The facility’s policy stated that residents are to be treated with kindness, dignity, and respect, and that residents shall be examined and treated in a manner that maintains the privacy of their bodies, with a closed door or drawn curtain shielding the resident from passers-by. During a medication administration observation, Resident 4 was sitting in a wheelchair in the hallway in front of Room A when an LVN prepared and administered one tablet of carbidopa-levodopa 100 mg and three tablets of sodium chloride 1 gram. The LVN administered the medications in the hallway while other residents and facility staff were passing by. The LVN later verified that Resident 4 was not provided privacy during the medication administration, and Resident 4 stated she preferred to receive her medications inside her room.
Unsafe Nightstand in Resident Room
Penalty
Summary
The facility failed to maintain a safe and homelike environment for Resident 86 because the resident's nightstand was not in good repair and safe condition. During the initial tour, the nightstand was observed beside the resident's bed with a bedside commode placed in front of it, the bottom drawer sticking out and unable to fully close, and the lower part of the wood on the side closest to the bed warped. Resident 86 was admitted to the facility and had the capacity to understand and make decisions, according to the H&P examination dated 2/22/26. During interviews, CNA 1 stated that Resident 86 used the bedside commode. Resident 86 stated she wanted the facility to fix or change the nightstand because she could tear her skin or bump her head on the broken furniture. Family Member 1 stated residents tend to lean toward the edge of the bed when sleeping and expressed concern that the resident might get injured with the broken nightstand. RN 1 verified the condition of the nightstand during observation and stated he would inform maintenance staff to fix or change it. The Administrator and DON were later informed and acknowledged the findings.
Care plans not updated for weight loss and contact isolation
Penalty
Summary
The facility failed to keep the comprehensive plan of care current for two residents whose needs had changed. Review of the facility’s policies showed the interdisciplinary team was expected to develop and implement a comprehensive person-centered care plan and to review the plan when a resident’s condition or care needs changed, including changes in weight. Surveyors found that the care plans for Resident 17 and Resident 75 were not revised to reflect their current care needs and interventions. Resident 17 was admitted and later readmitted to the facility, and the medical record showed the resident had the capacity to understand and make her own medication decisions. The physician’s orders included a fortified diet, easy-to-chew level 7 texture, and thin liquids. Weight records showed a decline from 131 lbs. to 125 lbs. and then to 111 lbs. within the month of January 2026, with continued weights of 112 lbs., 110 lbs., and 110 lbs. in February 2026. The care plan for nutrition, initiated on 1/7/26 and revised on 2/17/26, noted malnutrition and later a 20-lb. loss in one month, but it did not show a revision for the significant unplanned weight loss that occurred on 1/21/26. The DON reviewed the record and verified there was no change-in-condition assessment and no care plan addressing that weight loss. Resident 75 was admitted to the facility and had the capacity to understand and make decisions. The resident’s care plan for activity, dated 2/16/26, included inviting the resident to scheduled activities and allowing the resident to leave activities at any time. The physician later ordered contact isolation for shingles and single-room isolation, with services brought to the resident. During the initial tour, surveyors observed a contact isolation sign outside the room, and the resident stated she was in the room by herself and felt lonely. The resident later stated she never went out to activities and no staff came to offer room activities. The Activity Director confirmed the activity care plan was not revised when the resident was diagnosed with shingles and could not leave the room, and there was no documentation showing room activities were offered.
Failure to complete post-fall assessment and ordered treatments
Penalty
Summary
The facility failed to provide appropriate assessment and monitoring after an unwitnessed fall for a resident who lacked decision-making capacity and had multiple active orders, including apixaban, carvedilol, furosemide, spironolactone, and sacubitril-valsartan with hold parameters for low blood pressure and low heart rate. The resident was found sitting on the floor mat next to the bed, but the record did not show a post-fall physical assessment, post-fall vital signs, or documented neuro checks. Facility policy required a licensed nurse to complete a physical assessment after a fall, notify the physician and resident representative, and complete follow-up documentation and a fall risk evaluation, but the documentation reviewed did not show these steps were completed as required. The resident’s eInteract SBAR note documented vital signs and body system findings, but those vital signs were verified by staff to have been taken before the fall rather than after it. Nursing progress notes later showed the resident was found unresponsive and then pronounced dead, but the record did not show ongoing monitoring after the fall. Staff interviews confirmed that the post-fall vital signs should have been obtained after the unwitnessed fall, that body system assessments should have been completed, and that neuro checks should have been started for an unwitnessed fall; however, no neuro-check form was found in the chart. The DON also verified that the SBAR vital signs were not taken after the fall and that no neuro-check was available in the record. The facility also failed to follow the physician’s order for sacubitril-valsartan, which required blood pressure and heart rate to be checked and the medication held if systolic blood pressure was below 110 mmHg or heart rate was below 60 beats per minute. The MAR showed the medication was administered, but the record did not show blood pressure and heart rate were obtained before administration. In addition, the resident’s fall risk evaluation incorrectly indicated the resident was taking only 1-2 medications from the listed risk categories, even though the order summary showed eight medications in those categories. The facility also failed to provide a nutritional supplement ordered for another resident. That resident had an order for Magic Cup 4 ounces three times daily with meals, and the care plan included providing supplements as ordered. During a meal observation, the resident’s lunch tray and meal ticket indicated Magic Cup should have been present, but the tray did not contain it. Staff confirmed the kitchen had run out of Magic Cup, and the RD verified the meal ticket showed the supplement was ordered but unavailable.
Failure to Monitor and Document Urinary Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter by not monitoring and documenting urinary output as identified in the resident’s care plan. Resident 5 was admitted with an indwelling urinary catheter ordered for obstructive uropathy and urinary retention, and the care plan included an intervention to monitor intake and output of the catheter. However, review of the medical record did not show that fluid output was monitored or documented for the resident. During interviews, CNA 2 stated she emptied the drainage bag and reported the amount and color of urine to the LVN, but did not document the output because she believed the LVN would chart it. LVN 5 stated intake and output monitoring was not necessary unless there was a physician order and said staff only checked for leakage, urine clarity, and patency of the drainage bag. RN 1 stated the facility did not monitor intake and output for residents with indwelling catheters and that this was done in the acute care hospital setting, while the DON stated output should be documented in the task records but verified that no fluid output was being monitored and documented for Resident 5.
Failure to Notify Physician and Complete IDT Review for Significant Weight Loss
Penalty
Summary
The facility failed to provide necessary care and services related to weight loss for one resident who had a history of nutritional risk and was admitted with the capacity to understand and make her own medication decisions. The resident’s nutrition plan included Med Pass 2.0 twice daily, monitoring of weight, and a goal to maintain meal intake above 50% without significant weight changes. Her record also showed physician orders for Med Pass 2.0 and a health shake for nutritional support. The resident’s weights showed a loss from 130 lbs. to 125 lbs. in one week, then from 125 lbs. to 111 lbs. in another week, and later to 110 lbs. The record did not show that the physician was notified of the 5-lb. weight loss from 130 lbs. to 125 lbs. Staff interviews indicated the RNA said he verbally notified licensed nursing staff, while the LVN stated weight loss of 5 lbs. or more was reported to the RD and physician but could not find documentation that the physician had been informed. The record also showed a 14-lb. weight loss in one week, with an eINTERACT change in condition evaluation noting the physician and responsible party were made aware. However, the RD’s nutrition interdisciplinary team update dated 1/30/26 was still in progress and only listed the resident’s weight. A later RD note stated the resident might benefit from a fortified diet, and a physician order for a fortified diet was not entered until 20 days after the 14-lb. loss was identified. The record did not show new interventions or an IDT meeting to address the resident’s weight loss at that time, and the DON confirmed there was no IDT meeting or change in condition document regarding the earlier 5-lb. weight loss.
Respiratory Equipment and Oxygen Therapy Not Properly Ordered, Labeled, or Stored
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for Resident 86 by not having a physician’s order documented for oxygen therapy when the resident was observed using oxygen via nasal cannula at 3 liters per minute. RN 1 later verified that the medical record did not show an order for oxygen and stated that oxygen use required a physician’s order. The record later showed an order for continuous oxygen at 2 liters per minute via nasal cannula or mask to keep oxygen saturation above 90% for shortness of breath, but the resident was observed on multiple occasions receiving oxygen at 3 liters per minute instead of the ordered 2 liters per minute. Resident 86 also had nebulizer equipment that was not labeled and stored properly when not in use. The nebulizer mask and tubing were observed in the resident’s nightstand drawer on top of an unlabeled plastic bag, with fluid still present in the receptacle. The MDS Nurse verified the equipment was not emptied and was not stored in a bag labeled with the resident’s name and date, and stated it should have been. Resident 86’s record showed orders for albuterol sulfate inhalation nebulization solution for shortness of breath, and the medication had been administered on the prior evening and early morning. The facility also failed to properly manage nebulizer equipment for Resident 16 and Resident 51. Resident 16 had a nebulizer mask and tubing on the nightstand exposed to air, and the resident stated the equipment did not belong to her. LVN 4 verified the equipment was not in a labeled bag and acknowledged it should have been stored that way; the medical record did not show an order for nebulizer treatment. Resident 51’s nebulizer mask was observed on the bedside table and not stored in a set-up bag, and LVN 4 and the DON acknowledged it should have been stored in a bag to keep it clean and sanitary.
Failure to Administer Ordered Medication and Document Vital Signs for Held Antihypertensives
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for two residents. For one resident, an LVN administered multiple ordered medications during observation but failed to give a prescribed probiotic supplement ordered by the physician as one tablet by mouth daily. The resident’s record showed the order for the probiotic, and during interview the LVN verified that the supplement had not been administered as observed. The DON and Administrator were informed of the finding, and the DON stated licensed nurses needed to follow the five rights of medication administration and administer physician-ordered medications as ordered. The facility also failed to obtain and document blood pressure and heart rate before holding or administering two antihypertensive medications for another resident with hypertension. The resident had physician orders for amlodipine-olmesartan and metoprolol succinate, each with hold parameters for systolic blood pressure below 110 mmHg or heart rate below 60 bpm. On multiple dates, the MAR showed the medications were not administered and coded as held for low blood pressure, but the medical record did not show that blood pressure or heart rate had been obtained or documented at those times. An LVN, an RN, and the DON each verified that the vital signs should have been obtained and documented before the medications were held.
Medication Storage and Labeling Failures
Penalty
Summary
The facility failed to provide proper pharmacy services for storage and labeling of medications. During an inspection of Medication Cart A with an LVN, Resident 2’s hydrocodone-acetaminophen bubble pack was found with the blister for number 17 open, and Resident 19’s oxycodone bubble pack was found with the blister for number 25 open. The LVN verified both findings and stated the open blisters were not noticed when the controlled drugs were counted with the outgoing licensed nurse. The facility also failed to ensure proper labeling of an insulin pen stored in Medication Cart A. One Lantus Solostar pen was observed without a label showing the resident’s name, direction for use, physician’s name, or the pharmacy dispensing the medication. The LVN verified the finding and stated the medication should have been labeled to show who it belonged to, to prevent spread of infection. The DON later stated there should be no open bubble packs for controlled medications and that insulin pens should have labels with the resident’s name and direction for use. The facility further failed to keep a topical medication secure for Resident 33. During the initial tour, a pink cream and tongue depressor in a medication cup were observed on the resident’s bedside table, and the resident stated the cream was for her buttocks. Resident 33 had no capacity to understand and make decisions, and her record showed an order for antifungal cream 2% to the perineal area every shift. LVN 9 identified the cream as Calmoseptine and removed it from the bedside table, stating it should not have been left there. Review of the medical record did not show a physician’s order for Calmoseptine cream, and CNA 4 stated she had helped apply it earlier that morning.
Wound Vacuum Equipment Stored on Floor
Penalty
Summary
The facility failed to maintain infection control practices when Resident 24's wound vacuum machine and connector tubing were observed stored on the floor by the left side of the resident's head of the bed. During the initial tour, the wound vacuum equipment and tubing were seen on the floor, and an LVN later verified that the machine and tubing were on the floor and stated they should not be stored there for infection control. The facility's Infection Prevention and Control Program policy was reviewed and described a facility-wide infection prevention and control program involving coordination, oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Resident 24 had been admitted to the facility and had physician orders for a left lower leg wound vacuum, including irrigation with normal saline, packing with black foam, application of skin protectant and transparent dressing, continuous suction at 125 mmHg every shift, and use of a stocking, fiberglass splint, and ace wrap on scheduled days. A later interview with another LVN confirmed that the wound vacuum machine and connector tubing should be stored lower than the resident's wound but should not be on the floor. The DON was informed of and acknowledged the findings.
Failure to Provide Accurate COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure the necessary services related to COVID-19 vaccination were provided for two residents reviewed for immunizations. Facility policy required residents to be informed about the risks and potential side effects of the COVID-19 vaccine, to have their eligibility determined based on current CDC guidance, and to be offered the vaccine unless medically contraindicated, declined, or already immunized. The deficiency was identified through interview, medical record review, immunization document review, and facility policy review. Resident 5 was cognitively intact and had a California Immunization Registry record showing the last COVID-19 vaccine was received on 10/11/21, with a recommended seasonal vaccine date of 8/22/25 and the vaccine listed as past due. However, the resident's consent form dated 12/29/25 stated the resident declined vaccination because the resident was previously vaccinated and up to date, which the IP verified was inaccurate. Resident 7's consent form dated 7/22/25 similarly showed the responsible party declined vaccination because the resident was previously vaccinated and up to date, but review of the immunization record and medical record showed no record that Resident 7 had ever received a COVID-19 vaccine. The IP stated Resident 7 was not up to date and that education specific to eligibility and the risks and benefits of the vaccine was needed.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines as evidenced by improper storage, labeling, and maintenance of food items, as well as unsanitary kitchen equipment and conditions. Observations included pumpkin pies and bagels lacking expiration dates, a box of tater tots placed directly on the floor before being returned to the freezer, and a bottle of buttermilk ranch without an opened or expiration date. Additional findings included a bread knife with a melted handle, a missing tile on the drain near the ice maker, and a vent above the stove with a grey web-like formation. Several bread products were found with expired or missing dates, and staff confirmed these items should have been discarded or properly labeled. Further inspection revealed unsanitary kitchen equipment, such as pans with sticky residue and discoloration, a can opener with brown residue, and sticky stains on the floor between beverage machines. A melted and discolored pole with rust was also observed beneath the dish drying table. Staff interviews confirmed these findings and acknowledged the need for proper cleaning and maintenance. These deficiencies affected 57 of 59 residents who received dietary services from the facility's kitchen.
Failure to Follow Physician Orders and Develop Care Plans for Resident Safety Devices
Penalty
Summary
The facility failed to provide necessary care and services as ordered for two residents. For one resident with impaired memory, there was a physician's order specifying that the resident should be up in a chair for all meals. Despite this, multiple observations over several days showed the resident eating breakfast in bed, and staff interviews confirmed awareness of the order but did not consistently follow it. The resident indicated a preference to be in the wheelchair during meals, and staff acknowledged the importance of this positioning, particularly to help prevent aspiration, as the resident's bed could not be elevated to 90 degrees. For another resident with cognitive impairment, a wander-monitoring bracelet was in use for elopement prevention. However, the facility did not obtain a physician's order or develop a care plan for the use of the wander guard, as required by facility policy. Staff interviews and record reviews confirmed the absence of necessary documentation, including informed consent and a care plan, despite the resident wearing the device since admission.
Failure to Address and Manage Significant Resident Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to provide appropriate nutritional services to maintain acceptable parameters of nutritional status for three residents experiencing significant weight loss. For one resident with moderate cognitive impairment, there was a severe weight loss of 15 lbs in seven days. The Registered Dietitian (RD) recommended dietary fortification, but there was no documentation that these recommendations were communicated to the physician or addressed by the Nutrition Interdisciplinary Team (IDT). The Director of Nursing (DON) confirmed that the physician was not notified and no follow-up occurred regarding the resident's weight loss. Another resident, who was cognitively intact and receiving enteral nutrition, experienced an unplanned severe weight loss of 16 lbs (8.33%) in 21 days. The RD and IDT did not analyze or implement necessary interventions in response to this weight loss, and there was no evidence that the physician or the resident and/or their representative were notified. The care plan was not revised to address the significant weight loss, despite facility policy requiring such actions. Both the RD and DON verified the lack of evaluation, notification, and care plan updates for this resident. A third resident, with multiple comorbidities including CHF, diabetes, and CKD, had issues with meal refusal and missing documentation regarding food and fluid intake. The resident's weight upon admission was not accurately recorded, and there was no care plan developed to address the refusal of meals. Multiple instances of missing documentation for meal and fluid intake were identified, and staff confirmed that no care plan was initiated for the resident's meal refusals. The DON acknowledged that the facility failed to record the resident's weight at admission and verified the missing documentation.
Failure to Verify GT Placement Prior to Enteral Feeding
Penalty
Summary
The facility failed to ensure that a gastrostomy tube (GT) placement check was performed prior to initiating enteral feeding for a resident receiving tube feeding. According to the facility's policies and procedures, staff are required to verify tube placement before each feeding and medication administration by observing tube length, checking for respiratory distress, auscultating for a whooshing sound after injecting air, and checking the pH of aspirate. Physician orders for the resident also specified that tube placement and patency must be checked before and after giving medications and before starting tube feeding. On the day of the incident, a resident was observed in bed with the enteral feeding equipment connected but turned off. A registered nurse (RN) entered the room, primed and connected the enteral feeding tube, and started the feeding without checking the GT placement as required. The RN later confirmed that he did not verify the tube's placement before starting the feeding, acknowledging that this step should have been completed. The Director of Nursing (DON) was informed and acknowledged the findings.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents requiring oxygen therapy. For one resident, a physician's order specified continuous oxygen administration at two liters per minute via nasal cannula to maintain oxygen saturation above 90%. However, the resident was observed lying in bed with the oxygen set at 3.5 liters per minute, but the nasal cannula was not connected to the resident or the oxygen machine. The resident's oxygen saturation was found to be 86%, below the normal range, until the nasal cannula was properly applied and the oxygen flow adjusted to the ordered rate, resulting in improved saturation. For another resident with a diagnosis of acute respiratory failure with hypoxia, the facility failed to ensure that the nasal cannula tubing was dated and that a storage bag was provided for the tubing when not in use, as required by facility policy. The nasal cannula was observed to be undated and no storage bag was present. Staff confirmed that the required dating and storage procedures had not been followed for this resident.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 7.41%. During medication administration, a nurse did not follow physician orders for two residents. For one resident, metformin, which was ordered to be given with meals, was administered without food or a meal present. The nurse confirmed that the medication was not given as prescribed. The resident was cognitively intact, as indicated by a BIMS score of 13, and had an active order specifying the medication should be taken with meals for diabetes management. In another instance, the same nurse administered Advil (ibuprofen) to a resident who reported a pain level of 8, despite the physician's order specifying the medication was to be given only for mild to moderate pain (pain level 4-6). The nurse verified that the medication was given outside the prescribed pain level parameters. This resident was also cognitively intact, with a BIMS score of 15. These actions were not in accordance with the facility's policy and procedures for safe and timely medication administration as prescribed.
Medication Storage, Labeling, and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications as required by professional standards and its own policies. During inspections of two medication carts, surveyors observed that both carts were not maintained in a clean and sanitary manner, with visible dried residues and sticky medication build-up. Additionally, an expired bottle of Glucosamine Chondroitin Complex was found in one cart and had not been disposed of as required. These findings were verified by the licensed nursing staff present during the inspections. Further inspection of the Medication Storage Room revealed four expired bottles of docusate sodium that had not been properly disposed of. Medications intended for oral, rectal, and external use were found stored together on the same shelf, contrary to facility policy, which requires separation of oral and external medications. Facility staff, including the RN and DON, acknowledged these deficiencies during interviews. No specific residents or patient conditions were mentioned in relation to these findings.
Failure to Follow Menus, Recipes, and Physician Diet Orders
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received meals in accordance with physician orders and established recipes. During observation, a staff member did not follow the recipe for preparing pureed egg rolls and cream of rice, including not measuring ingredients and not following the correct sequence of preparation. The staff member acknowledged confusion and confirmed that the recipes were not followed as required. Additionally, several residents were not served the correct diet texture as ordered by their physicians. Five residents who were supposed to receive regular textured diets were instead served chopped textured food due to insufficient preparation of the regular textured Beef and Broccoli stir fry. This was confirmed by both the cook and the dietary resource, who stated there was not enough food prepared to meet the residents' prescribed dietary needs. Medical record reviews confirmed that these residents had specific physician orders for regular texture diets. Portion sizes were also not adhered to, as one resident received a smaller portion of Beef and Broccoli than ordered because the kitchen ran out of food. Another resident, who was supposed to receive a small portion of rice, was served using the wrong scoop size. Staff interviews confirmed that meal cards were not properly checked to ensure correct portion sizes were served. These failures were acknowledged by the staff and administration during the survey.
Incomplete Medical Record Documentation for Advance Directives and IV Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the Physician Orders for Life-Sustaining Treatment (POLST) form did not document whether the resident had formulated an advance directive or if this was discussed with the resident or their legally recognized decision maker. The form was later updated by the Social Services Director (SSD), but there was no documentation showing that the update was communicated to the resident's physician prior to the modification. The resident had a moderately impaired cognitive status, as indicated by a BIMS score of 9. For another resident, there was a lack of documented evidence that the peripheral IV site was monitored for complications or signs of infiltration during the administration of intravenous vancomycin for a wound infection. The resident was unable to recall details about the IV site, and the registered nurse confirmed that there was no documentation of IV site monitoring in the medical record. Both deficiencies were acknowledged by facility leadership during interviews.
Failure to Include Hospice Team in Interdisciplinary Care Planning
Penalty
Summary
The facility failed to ensure collaborative care planning between hospice and facility staff for a resident receiving hospice services, as required by both facility policy and the hospice contract agreement. According to the facility's policy, a coordinated plan of care involving the facility, hospice agency, and resident/family should be developed, with the hospice agency retaining overall professional management responsibility. The hospice services agreement also specifies that a registered nurse from the hospice agency is responsible for participating in interdisciplinary team (IDT) meetings. For one resident under hospice care, medical record review revealed that there was no documented evidence of hospice team participation in the IDT meeting following a significant change in the resident's condition. The resident was cognitively moderately impaired and had been admitted under hospice care. Interviews with facility staff, including the Infection Preventionist (IP), DON, and Administrator, confirmed that the hospice team was not included in the IDT meeting, despite their ongoing involvement in the resident's care.
Failure to Follow Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by staff, as evidenced by multiple observed incidents of non-compliance with hand hygiene protocols. An occupational therapy assistant (OTA) was observed assisting a resident to the bathroom, removing gloves, and then handling clean items and donning new gloves without performing hand hygiene. The OTA acknowledged not washing hands after glove removal, which was contrary to the facility's hand hygiene policy. Additionally, a licensed vocational nurse (LVN 1) was observed during medication administration for two residents, failing to perform hand hygiene before and after taking blood pressure, during medication preparation and administration, and between medication administrations for different residents. Another LVN (LVN 7) was observed assisting two residents with oxygen therapy, moving between them without changing gloves or performing hand hygiene. Both LVNs confirmed the observations and recognized the lapses in infection control. The facility's policies require hand hygiene before and after resident contact and after glove removal, but these were not followed during the observed events.
Failure to Maintain Kitchen Equipment and Temperature Monitoring
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a clean and safe operating condition, as evidenced by several observations and interviews. The ice machine was found with white flaky residue and brown buildup on both the outside panel and the base near the ice maker door. The Maintenance Director confirmed that cleaning focused only on the inside of the ice maker door and was unaware of the buildup on the exterior, despite the facility's policy requiring all equipment to be kept clean and in good repair. The low temperature dishwasher was observed with missing handle covers and brown discoloration on both handles. Additionally, chlorine levels in the dishwasher were found to be over 200 PPM, exceeding the posted reference range of 50-100 PPM. Dietary staff confirmed the excessive chlorine levels and indicated that an Ecolab technician had recently adjusted the machine, which may have caused the change. Despite this, the Dishmachine Temperature and Sanitizing Agent Log for the month showed only 100 PPM recorded for all previous checks, suggesting a discrepancy between actual and documented levels. Temperature monitoring of the residents' dining room refrigerator was also not performed according to facility policy. The temperature log lacked entries for the PM shift and was missing a recorded temperature for one morning. Staff and the Registered Dietitian verified that evening shift temperatures were not being recorded as required. These failures were acknowledged by facility leadership during the survey.
Failure to Ensure Dignity and Timely Medication Administration
Penalty
Summary
The facility failed to treat a resident with dignity during the removal of an indwelling urinary Foley catheter. The staff did not obtain permission from the resident for multiple staff members to be present during the procedure, which included two male and one female staff. The resident expressed feeling upset, embarrassed, and violated by the presence of multiple staff members, particularly male staff, during the procedure. Interviews with the staff involved confirmed that permission was not sought from the resident for the presence of additional staff, and the Director of Staff Development acknowledged that only one licensed nurse is typically required for such a procedure. Additionally, the facility failed to administer medications to the same resident in a timely manner. The medications scheduled for 0900 hours were not administered until 1030 hours, which is beyond the one-hour window specified in the facility's policy. The resident reported not receiving her knee patch and meloxicam for pain management, which affected her ability to participate in physical therapy. The Medication Administration Record confirmed the delay in administering the medications, and the Licensed Vocational Nurse verified the late administration. The Director of Nursing was made aware of both deficiencies and acknowledged the findings. The failure to treat the resident with dignity and the delay in medication administration had the potential to negatively impact the resident's well-being, as noted in the report.
Delayed Medication Administration for Resident
Penalty
Summary
The facility failed to provide timely pharmaceutical services to a resident, identified as Resident 2, by not administering medications as ordered. The facility's policy requires medications to be administered within one hour of their prescribed time. However, on the day of the survey, Resident 2 did not receive her scheduled 0900 hours medications until 1030 hours, which was beyond the one-hour window. This delay was confirmed through interviews with the resident and LVN 1, as well as a review of the Medication Administration Record (MAR) and Medication Admin Audit Report. Resident 2, who was admitted to the facility with diagnoses including muscle spasms, hypertension, multiple sclerosis, and osteoarthritis, reported not receiving her knee patch and meloxicam for pain management. The delay in medication administration was further corroborated by LVN 1, who acknowledged the late administration of medications. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Huntington Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sea Cliff Healthcare Center | 0 mi | ★★★★★ | 24 | 0 |
| Huntington Valley Healthcare Center | 1.4 mi | ★★★★★ | 44 | 0 |
| Fountain Valley Post Acute | 4 mi | ★★★★★ | 34 | 0 |
| Mesa Verde Post Acute Care Center | 4.6 mi | ★★★★★ | 25 | 0 |
| Victoria Healthcare And Rehabilitation Center | 5.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.