Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Post Acute during CMS and state inspections, most recent first.
The facility failed to maintain grooming care for multiple residents who needed ADL assistance. Several residents with cognitive impairment, dementia, Parkinson's disease, and other conditions were observed with long, jagged fingernails, and two residents with mycotic toenails were not seen by podiatry despite standing orders. Staff interviews confirmed that long or dirty nails could cause discomfort and that the residents should have received nail care and podiatry services.
Improper Storage of Frozen Food Items: Open bags of frozen pizza dough, corn, potato puffs, and hotdogs were found stored in the reach-in freezer without being sealed in airtight containers or bags. Ice crystals were observed on some items, and the DS, DA, and RD stated frozen foods should be stored in sealed packaging to prevent freezer burn and maintain food quality.
The facility failed to follow infection control practices during tray delivery and medication administration. A CNA passed lunch trays between residents without hand hygiene, and an LVN did not perform hand hygiene before, during, or after a medication pass for a resident with hemiplegia, dysphagia, severe cognitive impairment, and a GT. The LVN also did not wear gloves or a protective gown for the resident on EBP and used Clorox wipes on his hands instead of ABHR or soap and water.
Improper NOMNC Signatures and Notification: Two residents with intact cognition and capacity to make decisions were not appropriately notified of Medicare coverage changes. One resident denied seeing or signing the NOMNC, while the BOM acknowledged she signed both NOMNC forms even though she was not the resident or representative. The DON stated only the resident or representative should sign, and the facility policy required timely Medicare notices to the resident and/or representative.
Failure to Notify Ombudsman of Resident Transfer: A resident with DM, muscle weakness, dementia, severe cognitive impairment, and total dependence with ADLs was transferred to a GACH for low hemoglobin, but the facility did not ensure the Ombudsman was notified as required. The ADON and DON stated the Ombudsman should be informed immediately or the same day of such transfers, and the facility policy required sending a copy of the transfer/discharge notice to the State LTC Ombudsman.
A resident with diagnoses including Alzheimer’s disease, depression, anxiety disorder, and bipolar disorder had a positive PASRR Level I for SMI and was receiving Latuda for bipolar disorder, but the required PASRR Level II evaluation was not obtained. The MDS nurse confirmed the positive screening, stated a Level II should have been completed, and did not know why it was not done; the facility policy stated positive Level I results for mental illness were to be sent for Level II prescreening.
An LVN failed to verify GT placement and check GRV before administering medications to a resident with dysphagia, a GT, and severely impaired cognitive skills. The resident’s orders required GT placement/patency checks and residual checks every shift, and the facility policy required tube placement verification and residual checks before medication administration.
Staff were not consistently informed of PTSD triggers for two residents with PTSD. One resident’s care plan identified being touched by male personnel as a trigger, and another resident’s care plan identified loud noises and yelling; however, CNAs stated they were not made aware of these triggers unless the residents told them directly. Interviews with the resident, CNAs, RNS, and DON confirmed that staff awareness of PTSD triggers was lacking despite the residents having intact cognition and requiring maximal assistance with ADLs.
Failure to Ensure Podiatry Services for Two Residents: The SSD failed to ensure two residents with standing podiatry orders were seen for treatment of long, jagged mycotic toenails. Both residents had intact cognition, needed assistance with ADLs and hygiene/grooming, and were observed with overgrown toenails that they said were too long and uncomfortable. The SSD stated the residents were not seen because of insurance and that she forgot to schedule another podiatry appointment; the DON and Administrator stated the facility was responsible for providing the needed care and services.
A resident with a GT, dysphagia, and severe cognitive impairment received meds through the GT without the LVN verifying tube placement or checking gastric residuals, despite orders and facility policy requiring both. In a separate event, an LPN administered metoprolol to a resident with HTN without checking the pulse rate even though the order included a hold parameter for pulse less than 60 bpm. The DON and other staff confirmed the expected checks were not completed.
Improper Storage of Discontinued and Expired Medications: A resident’s discontinued Risperidone remained in a box labeled extra medicines in the med room instead of being removed from active storage, and an expired hemorrhoidal ointment was also found stored on a shelf. The LVN and DON acknowledged the discontinued medication should not have been kept with usable meds, and the facility policy required expired or discontinued meds to be separated and later destroyed.
Dish Machine Chlorine Test Strips Misread by Dietary Staff: Dietary staff were observed and interviewed while checking chlorine in the dish machine, and both DAs stated they estimated strip readings instead of interpreting the color chart correctly. The Dish Machine Temperature Log showed several recorded ppm values that did not match the chart, and the DS stated staff had been told to read the strips by estimating. The facility P&P required chlorine to read 50-100 ppm on the dish surface in the final rinse.
A resident consented to receive a pneumococcal vaccine, but due to nausea and vomiting, the Infection Preventionist held the vaccine without documenting the decision or informing the team for follow-up. The Director of Nursing and Administrator confirmed that documentation should occur, and the facility's policy requires recording whether the vaccine is administered or withheld.
A resident receiving renal dialysis and medications for heart rate and blood pressure refused dialysis twice and medication multiple times. The facility failed to notify the resident's doctor of these refusals, contrary to policy. Staff were aware of the refusals but did not document or inform the physician, potentially delaying medical intervention.
Two residents were prohibited from using motorized wheelchairs in the facility, affecting their dignity and independence. Resident 1, with hemiplegia, and Resident 2, with encephalopathy, expressed dissatisfaction with the ban, which was implemented due to safety concerns. Staff reported no incidents with motorized wheelchairs, and the facility's policy allows their use if deemed safe by a physician and interdisciplinary team.
The facility failed to ensure the microwave in the rehab gym was used for its intended purpose, instead using it to store plastic utensils, straws, and paper plates. This misuse was acknowledged by both the Director of Rehabilitation and the Maintenance Supervisor, and it was found to be against the manufacturer's safety guidelines and the facility's Preventative Maintenance Policy.
The facility failed to maintain a resident's dignity and hygiene by not emptying a urinal in a timely manner, leaving it 90% filled with urine on the bedside table near food and drinks. This oversight was confirmed by staff interviews and violated the facility's policies on ADLs and hygiene standards.
The facility failed to develop and implement an individualized care plan for a resident with severe range of motion (ROM) limitations in the left shoulder. Despite being identified upon admission, the care plan did not include goals or interventions to maintain or prevent a decline in the resident's joint ROM. Observations and interviews revealed that the resident experienced significant stiffness and atrophy in both arms and hands, affecting daily activities. The facility's policy emphasized the importance of comprehensive care plans, but this was not adhered to, potentially impacting the resident's well-being.
The facility failed to provide adequate ADL care and hygiene for a resident, resulting in poor hygiene, disheveled appearance, and feelings of embarrassment. The resident did not receive scheduled showers, grooming, or proper care planning for refusal of care, as confirmed by staff interviews and observations.
The facility failed to provide treatments and services to maintain and limit a decline in joint range of motion (ROM) for a resident. Despite severe ROM limitations identified upon admission, the resident did not receive Occupational Therapy (OT) or Restorative Nursing Aide (RNA) services for the arms. Observations and interviews revealed increased stiffness and atrophy in the resident's arms and hands, affecting daily activities. The facility's policy requiring skilled therapy and RNA services for identified ROM limitations was not followed.
The facility failed to ensure CNAs received the required abuse and dementia training, as evidenced by incomplete pre-tests and post-tests for abuse training and lack of documentation for dementia training. This deficiency was confirmed by the DSD and DON, highlighting a gap in validating staff competency.
The facility failed to conduct annual performance evaluations for a CNA who had been working since 2019. The CNA did not receive an evaluation for 2023, and another evaluation for 2024 was also due. Both the DSD and DON confirmed that these evaluations are essential for assessing staff quality of work, knowledge, and skills, and for identifying areas needing improvement.
A resident with multiple diagnoses, including MRSA infection, did not receive prescribed antibiotics within the scheduled time frame. The Vancomycin Hydrochloride was administered hours later than ordered, as confirmed by the ADON and DON. Facility policy requires medications to be given within 60 minutes of the scheduled time and recorded immediately after administration.
Failure to Maintain Resident Grooming and Podiatry Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform ADLs received appropriate grooming care. Seven sampled residents were identified with unmet grooming needs, including five residents with long, jagged fingernails and two residents with long, jagged mycotic toenails who had not been seen by podiatry as ordered. The report states these failures involved Residents 1, 10, 45, 52, 54, 55, and 67. Resident 1 had diagnoses including DM, muscle weakness, and dementia, was totally dependent on staff for personal hygiene, and was assessed as having moderate cognitive impairment with substantial to maximal assistance needed for ADLs. During observation, Resident 1 was seen with long, jagged fingernails and stated he wanted them trimmed. Resident 10 had diagnoses including DM, muscle weakness, and dementia, was totally dependent with ADLs, and was observed with long, jagged fingernails. Resident 45 had schizoaffective disorder, muscle weakness, and anxiety, needed assistance with personal hygiene, and was observed with long, jagged fingernails; the resident stated he wanted them trimmed. Resident 52 had dementia and bipolar disorder, was severely cognitively impaired, required maximal assistance with ADLs, and was observed with long and dirty fingernails that required trimming and cleaning. Resident 54 had Parkinson's disease, muscle weakness, and lack of coordination, needed moderate assistance with personal hygiene, and was observed with long, jagged fingernails; the resident stated they were too long and needed trimming. Resident 55 had Parkinson's disease, muscle weakness, and DM, was totally dependent with personal hygiene and ADLs, and had a standing order to see podiatry every two months and as needed for mycotic and/or other foot problems. Resident 55 was observed with long, jagged mycotic toenails and stated they were too long. Resident 67 had spinal stenosis, muscle weakness, and chronic kidney disease, needed moderate assistance with personal hygiene, and also had a standing podiatry order for mycotic toenails and/or other foot problems. A list of residents seen by podiatry showed Residents 55 and 67 were not seen due to insurance, and the SSD stated it was her responsibility to ensure they were seen and that the facility should have paid for the podiatrist visit when the podiatrist last came to the facility. Resident 67 was later observed with long, jagged mycotic toenails and stated they were too long and very uncomfortable when wearing socks.
Improper Storage of Frozen Food Items
Penalty
Summary
The facility failed to store food in a safe and sanitary manner for 69 residents receiving oral diets. During a concurrent initial kitchen observation and interview on 5/26/2026 at 8:20 a.m., an open plastic bag containing frozen pizza dough, an open blue bag containing frozen corn inside a brown box, an open bag of frozen potato puffs, and an open bag of frozen hotdogs were observed stored in the reach-in freezer. Crystalized ice was observed on the potato puffs and hotdogs, and the Dietary Supervisor stated the frozen food items should have been tied closed or stored in sealed plastic bags or containers. During interviews, the Dietary Aide stated open frozen items should be stored in a Ziplock bag or tied with a knot so ice crystals would not form on the food, and stated the ice crystals could contaminate frozen food and could lead to food-borne illness. The Dietary Supervisor stated open frozen items not stored in an airtight, sealed container could cause food-borne illness and decrease the quality of food served to residents. The Registered Dietitian stated improper storage of frozen food items could decrease the flavor and quality of food. The facility policy titled Procedure for Freezer Storage, dated 2023, stated frozen foods will be stored in airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn.
Infection Control Practices Not Followed During Tray Delivery and Medication Pass
Penalty
Summary
The facility failed to maintain and observe infection control practices during meal tray delivery and medication administration. During a concurrent observation and interview on 5/26/2026 at 12:11 p.m., CNA 2 was observed going room to room passing lunch trays without performing hand hygiene between residents. CNA 2 stated he was supposed to perform hand hygiene between each resident's tray because not doing so could spread bacteria between residents and could cause them to get sick. The Infection Control Nurse and the DON later stated staff should perform hand hygiene between residents when passing meal trays and before and after entering residents' rooms when passing meal trays. The facility also failed to ensure hand hygiene and required infection control practices were followed during medication administration for Resident 20. Resident 20 had diagnoses including hemiplegia affecting the right dominant side, dysphagia, and gastrostomy, and the MDS indicated severely impaired cognitive skills and need for substantial to maximal assistance with several activities of daily living. The resident's H&P stated the resident did not have the capacity to understand and make decisions. During a medication pass observation on 5/26/2026 at 4:00 p.m., LVN 1 did not perform hand hygiene before taking vital signs, before preparing and crushing medications, or before administering medications via the gastrostomy tube. LVN 1 also did not wear gloves or a protective gown before taking vital signs or administering medications through the GT, and after administering the medications, wiped his hands with Clorox wipes. During interviews, LVN 1 stated he had forgotten to perform hand hygiene and then continued not performing it during the medication pass. LVN 3 stated licensed nurses should wear gloves, a mask, and a protective gown when a resident was on EBP, and that Clorox wipes should not be used for hand hygiene. The Infection Preventionist Nurse stated Resident 20 was on EBP because of the gastrostomy tube and that LVN 1 should have practiced hand hygiene and worn PPE before administering medications. The DON stated LVN 1's failure to perform hand hygiene and wear PPE during the medication pass could spread infection among residents and staff due to contamination from his hands.
Improper NOMNC Signatures and Notification
Penalty
Summary
The facility failed to ensure that two sampled residents, Resident 33 and Resident 88, were appropriately notified of changes in their Medicare coverage through provision of the Notice of Medicare Non-Coverage (NOMNC) form. Resident 33 was admitted with diagnoses including HTN and DM, and the MDS indicated intact cognition, maximal assistance with ADLs, and the H&P stated the resident had the capacity to understand and make decisions. Resident 88 was admitted with diagnoses including depression and severe chronic kidney disease, and the MDS indicated intact cognition with supervision needed for ADLs; the H&P also stated the resident had the capacity to understand and make decisions. During an interview on 5/28/2026, Resident 33 denied that the signature on the NOMNC form was his and denied having seen or ever being presented with the form. In a concurrent interview and record review, the BOM stated she had signed the NOMNC forms for Residents 33 and 88, but acknowledged she should not have signed them because she was not the resident or the resident representative. The BOM stated signing the forms without the residents' consent or knowledge could cause a loss of trust and affect their rights. The DON stated the NOMNC forms should only be signed by the resident or resident representative, not the BOM. The facility policy stated it is the facility's responsibility to ensure Medicare notice forms are completed as per Medicare guidelines and given to the resident and/or representative timely.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure the Ombudsman was notified when Resident 10 was hospitalized and transferred to a general acute care hospital. Resident 10 was admitted to the facility and later readmitted, and had diagnoses including diabetes mellitus, muscle weakness, and dementia. The resident’s H&P dated 1/27/26 stated that Resident 10 did not have the capacity to understand and make decisions, and the MDS dated 5/4/26 indicated severe cognitive impairment and total dependence with ADLs. Resident 10’s physician discharge summary indicated the resident was discharged to the GACH on 3/9/26 for low hemoglobin. During concurrent interview and record review, the ADON reviewed the Notice of Transfer/Discharge and stated the Ombudsman should be notified the same day when residents were transferred to the GACH so the Ombudsman would be aware the resident was no longer in the facility and could ensure the discharge was appropriate. The DON also stated the Ombudsman should be notified immediately after a resident was transferred to the GACH. The facility policy titled Discharge Process stated that a copy of the notice would be sent to a representative of the Office of the State Long-Term Care Ombudsman and the reason, effective date, and location of transfer or discharge would be recorded in the resident’s medical record.
PASRR Level II Evaluation Not Obtained After Positive Level I Screening
Penalty
Summary
The facility failed to ensure that one of three sampled residents, Resident 6, who had a positive PASRR Level I screening for serious mental illness, received the required PASRR Level II evaluation before admission. Resident 6’s record showed diagnoses of Alzheimer’s disease, depression, anxiety disorder, and bipolar disorder, and the MAR dated 2/3/2025 showed Latuda 20 mg by mouth in the evening for bipolar disorder manifested by mood swings from being sociable to keeping to self. The PASRR Level I screening dated 3/13/2025 indicated a positive result for SMI, and the care plan later referenced a Level II PASRR recommendation and a Level II evaluation date of 7/13/2026. Record review also showed progress notes describing the resident’s mood as steady with persistent depressive features, an H&P stating the resident had the capacity to understand and make decisions, and later progress notes describing severe cognitive impairment consistent with advanced neurocognitive decline in a highly supervised care setting. During interview, the MDS nurse stated she was responsible for screening residents, confirmed that Resident 6’s diagnoses and Latuda use were considered relevant for PASRR purposes, and stated that a Level II evaluation should have been completed after the positive Level I screening. She stated she did not know why the Level II evaluation had not been obtained and explained that the purpose of Level II was to assess mental health needs and determine whether specialized services were required. The facility policy stated that a positive Level I screening due to diagnosed or suspected mental illness would be automatically sent to the DHCS contractor for a Level II prescreening call.
Failure to Verify GT Placement and Residual Before Medication Administration
Penalty
Summary
Licensed Vocational Nurse 1 failed to verify the placement of Resident 20’s gastrostomy tube and failed to check the gastric residual volume before administering medications through the tube. During medication administration observation, LVN 1 did not verify or assess GT placement and did not check the GRV prior to giving medications. In interview, LVN 1 stated he forgot to check the GT placement and gastric residual before administering the medications and acknowledged that he should have verified both before use. Resident 20 was admitted and later readmitted to the facility with diagnoses including hemiplegia affecting the right dominant side, dysphagia, and gastrostomy. The resident’s MDS indicated severely impaired cognitive skills and need for substantial to maximal assistance with several activities of daily living, and the H&P stated the resident did not have the capacity to understand and make decisions. The order summary required GT placement and patency checks every shift and residual checks every shift, and the facility’s policy for medication administration via enteral tube required verification of tube placement and checking residual amounts before administering medications.
Failure to Inform Staff of PTSD Triggers
Penalty
Summary
The facility failed to ensure staff were informed of and provided individualized, trauma-informed care for residents with PTSD. Two of three residents reviewed for PTSD, Residents 28 and 66, had care plans identifying specific triggers, but staff interviews showed that CNAs were not consistently aware of those triggers. Resident 28’s care plan identified being touched by male personnel as a trigger, and Resident 66’s care plan identified loud noises and yelling as triggers. Both residents had diagnoses including PTSD, and both MDS assessments indicated intact cognition and maximal assistance with ADLs. During interviews, Resident 66 stated his PTSD triggers included loud noises and fighting people. CNA 4 stated she had not been made aware of which residents had PTSD or their triggers unless residents told her themselves, and she knew Resident 66’s triggers only because he informed her. CNA 3 stated she had not been aware that Resident 28 had PTSD or what his triggers were. RNS 1 and the DON stated staff needed to know which residents had PTSD and their triggers so they would not trigger the residents and so the residents would feel safe and comfortable. The facility policy stated residents with trauma and/or PTSD would receive appropriate person-centered and individualized treatment and services to meet assessed needs.
Failure to Ensure Podiatry Services for Two Residents
Penalty
Summary
The facility's Social Services Director failed to ensure two residents were seen by a podiatrist for treatment of long, jagged mycotic toenails. Resident 55 was admitted with Parkinson's disease, muscle weakness, and DM, had intact cognition and decision-making capacity, and was totally dependent for personal hygiene. Resident 55's care plan included hygiene and grooming support, and the order summary showed a standing order for podiatry every two months and as needed for mycotic and/or other foot problems. Resident 67 was admitted and later readmitted with spinal stenosis, muscle weakness, and chronic kidney disease, had intact cognition and decision-making capacity, and required substantial to maximal assistance with ADLs. Resident 67's care plan also included hygiene and grooming support, and the order summary showed a standing order for podiatry every two months and as needed for mycotic toenails and/or other foot problems. During observation, both residents were found to have long, jagged mycotic toenails, and both stated their toenails needed trimming because they were too long. During interview and record review, the SSD reviewed a list of residents seen by podiatry and stated Residents 55 and 67 were not seen because of their insurance. The SSD stated it was her responsibility to ensure the residents were seen by the podiatrist and that the facility should have paid for the toenail trimming when the podiatrist last visited the facility. The SSD stated she had forgotten to schedule another podiatry appointment for the two residents. The DON and Administrator stated the facility was responsible for providing the care and services the residents needed, and the Administrator stated both residents should have been seen by podiatry.
Failure to Verify GT Placement and Assess Pulse Before Medication Administration
Penalty
Summary
Medication administration was not carried out in accordance with accepted standards of practice for a resident with a gastrostomy tube. The resident had diagnoses including hemiplegia affecting the right dominant side, dysphagia, and gastrostomy, and the record showed orders to check GT placement and patency every shift and to check residuals every shift. During an observed medication pass, an LVN administered medications through the GT without verifying tube placement and without checking the gastric residual volume before giving the medications. During interview, the LVN stated he forgot to check the GT placement and gastric residual before administering the medications and acknowledged he should have verified both. The Infection Preventionist Nurse stated licensed nurses must verify GT placement and check the gastric residual before administering medications through the GT. The DON also stated licensed nurses should check and verify GT placement before administering medications through the GT, and the facility policy on enteral tube medication administration stated the nurse will verify tube placement and then check residual amounts before administering medications. Medication administration was also not carried out in accordance with the physician order for another resident receiving metoprolol. The resident had diagnoses including hypertension, cardiac murmur, and muscle weakness, and the order directed metoprolol tartrate twice daily with instructions to hold the medication if systolic blood pressure was less than 110 mmHg and pulse rate was less than 60 bpm. During a medication pass observation, an LVN obtained the resident's blood pressure but stated she only takes pulse when required by medication parameters, then administered metoprolol without assessing the pulse rate. The LVN later acknowledged the order included a pulse hold parameter and that she did not check the pulse rate, and the DON stated the nurse should check medication instructions, including hold parameters, before administration.
Improper Storage of Discontinued and Expired Medications
Penalty
Summary
Medications and biologicals were not stored in accordance with accepted professional principles in one of two medication storage rooms. During observation and interview, a clear plastic box labeled for extra medicines contained an unopen bubble pack of Resident 40’s Risperidone 1 mg, even though the medication had been discontinued and the resident’s dose had been changed to Risperdal 2 mg. An empty clear plastic box labeled discontinued medicines was also present in the room. The LVN stated the discontinued Risperidone should have been discarded and not kept in the extra medicines box, and later stated it should have been placed in the discontinued medicines box for destruction. Resident 40’s record showed admission diagnoses including schizoaffective disorder, bipolar disorder, PTSD, and depression. The H&P stated the resident had the capacity to understand and make decisions. Physician orders showed Risperdal 2 mg twice daily and Risperdal 1 mg two tablets at bedtime were both discontinued on 5/7/2026. Despite those discontinuations, the Risperidone 1 mg bubble pack remained in the medication storage room in the box labeled extra medicines during the survey observation. An expired hemorrhoidal ointment with an expiration date of 8/2025 was also observed stored on a shelf in the medication storage room. The LVN stated the expired ointment would not be effective because its potency decreased when used on residents. The DON stated storing the expired ointment created a risk it could be used on residents and would not be effective. The facility policy stated expired medications and medications discontinued by a prescriber are to be marked as discontinued or stored separately and later destroyed.
Dish Machine Chlorine Test Strips Misread by Dietary Staff
Penalty
Summary
Food service staff were not competent in reading test strips used to check chlorine levels in the dishwashing machine. During a concurrent observation and interview, Dietary Aide 1 demonstrated how to test the final rinse water by dipping a strip and comparing it to the color chart, and stated the strip read 50 ppm with the kitchen following a 50-200 ppm chlorine range. However, review of the kitchen Dish Machine Temperature Log for 5/2026 showed multiple entries of 58, 59, 60, 68, 69, and 70 ppm on various breakfast and lunch dates. During interviews and record review, Dietary Aide 1 stated those readings were not correct interpretations because the chlorine color chart only showed a range of 50-100 ppm, and she had estimated the readings after being told to read them that way. Dietary Aide 2 stated she also approximated chlorine levels based on how the strip became darker or lighter and acknowledged she had not been reading the strips correctly. The Dietary Supervisor stated staff had been instructed to estimate the readings, and the facility policy for DishWashing stated chlorine should read 50-100 ppm on the dish surface in the final rinse.
Failure to Document and Follow Up on Pneumococcal Vaccine Administration
Penalty
Summary
The facility failed to follow up on and document the administration of a pneumococcal vaccine for a resident who had consented to receive it. The resident, who was admitted with diagnoses including diabetes mellitus, generalized muscle weakness, and dysphagia, had intact cognition and required moderate assistance with daily activities. Despite consenting to the vaccine, the resident experienced nausea and vomiting on the day it was to be administered, leading the Infection Preventionist (IP) to hold the vaccine due to medical contraindication. However, the IP did not document this decision in the resident's clinical record or inform the team for follow-up. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that documentation of vaccine administration or reasons for non-administration should be recorded in the resident's clinical record. The facility's policy indicated that such documentation is necessary, whether the vaccine is given or withheld due to medical contraindications or refusal. The lack of documentation and follow-up potentially exposed the resident to the risk of contracting pneumonia, as the vaccine was not administered despite the resident's consent.
Failure to Notify Physician of Resident's Refusal of Dialysis and Medication
Penalty
Summary
The facility failed to inform a resident's primary care doctor about the resident's refusal of dialysis and medication, which could have delayed medical intervention. The resident, who was receiving renal dialysis and medications for elevated heart rate and blood pressure, refused dialysis on two occasions and medication on multiple occasions. Despite the facility's policy requiring physician notification within 72 hours of a resident's refusal of care, the resident's doctor was not informed of these refusals. Interviews and record reviews revealed that the Licensed Vocational Nurse and Registered Nurse were aware of the resident's refusals but failed to document or notify the physician as required. The Director of Nursing acknowledged that the physician should be notified of new or repeated refusals, especially for dialysis, due to the risk of fluid overload. However, the physician had previously instructed the DON to stop notifying him about medication refusals and to continue offering the medications to the resident.
Prohibition of Motorized Wheelchairs Affects Resident Dignity
Penalty
Summary
The facility failed to maintain and enhance the dignity of residents by prohibiting the use of motorized wheelchairs for two residents, despite their need for such devices due to physical impairments. Resident 1, who has hemiplegia and hemiparesis following a stroke, was informed on July 1, 2024, that he could no longer use his motorized wheelchair within the facility. This decision was made without providing a specific reason, and the resident's motorized wheelchair was taken away. Resident 1 expressed that the inability to use the motorized wheelchair made him feel bad about himself and lose his independence, as he relied on it to move around the facility independently. Similarly, Resident 2, who has encephalopathy and difficulty walking, was also prohibited from using his motorized wheelchair in the facility. He had been using the motorized wheelchair for three to four months before the ban was implemented. Resident 2 expressed dissatisfaction with the new policy and mentioned that he might leave the facility if the restriction continued. Both residents required assistance from staff to move around the facility in manual wheelchairs, which affected their independence and psychosocial well-being. The facility's administration cited safety concerns and narrow hallways as reasons for the ban on motorized wheelchairs. The Administrator mentioned that the policy was based on a review of existing policies and discussions during Quality Assurance Performance Improvement Committee Meetings. However, staff members, including a CNA and an LVN, reported not observing any incidents involving motorized wheelchairs. The facility's policy allows for the use of motorized wheelchairs if assessed as safe by the resident's physician and interdisciplinary team, but this assessment was not conducted before the ban was implemented.
Improper Use of Microwave for Storage in Rehab Gym
Penalty
Summary
The facility failed to ensure the microwave in the rehabilitation gym was used for its intended purpose and in accordance with the manufacturer's guidelines. During an observation and interview, it was found that the microwave was being used to store plastic utensils, plastic straws, and paper plates. The Director of Rehabilitation acknowledged that the microwave was in working order and should not be used as a storage unit, as it could cause burns or a fire. The Maintenance Supervisor also confirmed that the microwave should only be used to heat food and not for storage purposes, as this could result in fire, burns, or injury. A review of the manufacturer's User's Manual for the microwave indicated that the microwave cavity must not be used for storage purposes and that failure to follow these safety instructions could result in burns, electrical shock, fire, or injury. Additionally, the facility's Preventative Maintenance Policy stated that all equipment should be maintained according to the manufacturer's guidelines to prevent unsafe environments and injuries. The facility's failure to adhere to these guidelines had the potential to cause harm to staff, residents, or visitors.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for Resident 39. Specifically, the facility did not empty Resident 39's urinal in a timely manner, leaving it 90% filled with urine on the resident's bedside table, close to cups of water and coffee. This oversight was observed during a concurrent observation and interview with a Certified Nurse Assistant (CNA), who admitted responsibility for emptying the urinal but stated she had not noticed it was full. The resident's medical history includes diagnoses of HIV, atrial fibrillation, and type 2 diabetes mellitus, and the resident requires partial/moderate assistance for various activities of daily living (ADLs) such as oral hygiene, toileting hygiene, and personal hygiene. Further interviews with a Licensed Vocational Nurse (LVN) and the Director of Nursing Service (DON) confirmed that CNAs are expected to check and empty urinals after each use and that urinals should not be placed near food or on bedside tables due to the risk of cross-contamination. The facility's policy and procedure on ADLs and Scope of Services also indicate that CNAs should assist residents with toileting and maintain hygiene standards. The failure to adhere to these protocols resulted in Resident 39 feeling embarrassed and had the potential to lower the resident's self-esteem.
Failure to Develop and Implement Individualized Care Plan for Resident with Severe ROM Limitations
Penalty
Summary
The facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to address the severe range of motion (ROM) limitations in the left shoulder of Resident 25. Upon admission, Resident 25 was identified as having severe ROM limitations in the left shoulder and within functional limits (WFL) ROM in other joints. Despite these findings, the care plan did not include any goals or interventions to maintain or prevent a decline in the resident's joint ROM of both arms. This oversight was confirmed during a review of the resident's care plan and interviews with the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Nurse (MDSN), who acknowledged the absence of a comprehensive care plan addressing the resident's ROM limitations. Observations and interviews with Resident 25 revealed that the resident experienced significant stiffness and atrophy in both arms and hands, which affected daily activities such as holding utensils and opening containers. The resident reported that staff assisted with leg exercises but did not provide any exercises for the arms, despite the resident's request for assistance due to stiffness. This lack of intervention was further evidenced during a Restorative Nursing Aide (RNA) session, where the RNA only provided leg exercises and stated that the order did not include arm exercises. The Director of Nursing (DON) and the facility's policy and procedure (P&P) emphasized the importance of developing comprehensive, person-centered care plans that include measurable objectives and timetables to meet the resident's needs. However, the facility failed to adhere to this policy, resulting in the absence of a care plan for Resident 25's severe ROM limitations. This failure had the potential to negatively impact the resident's physical functioning and overall well-being.
Failure to Provide Adequate ADL Care and Hygiene for Resident
Penalty
Summary
The facility failed to ensure that Resident 50 received adequate care and services to perform activities of daily living (ADLs) since their re-admission. Specifically, the facility did not provide showers or bed baths, grooming services such as haircuts and nail trimming, and did not care plan for Resident 50's refusal of care. These failures resulted in Resident 50 experiencing poor hygiene, appearing disheveled, and feeling embarrassed and unkempt. Observations and interviews revealed that Resident 50 had disheveled hair and beard, untrimmed fingernails, and had not received a shower since re-admission. The resident stated that requests for shaving were either ignored or performed roughly by staff, leading to further discomfort and neglect of personal hygiene. Interviews with CNAs and the MDS Coordinator confirmed that Resident 50's scheduled showers and personal hygiene needs were not being met. The MDS Coordinator and the Director of Nursing acknowledged the importance of care planning for refusals of care but admitted that this was overlooked in Resident 50's case. The facility's policy and procedure on ADLs emphasized the necessity of providing care to maintain residents' highest practicable physical, mental, and psychosocial well-being, which was not adhered to in this instance.
Failure to Provide ROM Treatments for Resident
Penalty
Summary
The facility failed to provide treatments and services to maintain and limit a decline in joint range of motion (ROM) for Resident 25. Despite being admitted with severe ROM limitations in the left shoulder and within functional limits (WFL) ROM in the right shoulder, both elbows, both wrists, and both hands/fingers, Resident 25 did not receive Occupational Therapy (OT) or Restorative Nursing Aide (RNA) services for the arms. The resident's Joint Mobility Assessments (JMA) conducted on 12/21/2023 and 3/21/2024 did not include an assessment of the arms, and there were no care plans or interventions in place to address the maintenance of ROM for the arms, despite the severe limitations identified upon admission on 9/18/2023. During observations and interviews, it was noted that Resident 25 experienced increased stiffness and atrophy in both arms and hands, affecting his ability to perform daily activities such as feeding himself. The resident reported that staff assisted with leg exercises but not with arm exercises. RNA 1 confirmed that the RNA order was only for leg exercises and stated that the resident could benefit from arm exercises. The Director of Rehabilitation (DOR) confirmed that Resident 25 was not seen by OT during his stay and that there were no orders for arm exercises until 4/17/2024, when an RNA order was written without a prior assessment. The Minimum Data Set Coordinator (MDSC) and Minimum Data Set Nurse (MDSN) confirmed that the quarterly JMAs did not assess the resident's arms and that there were no interventions in place to maintain or prevent a decline in ROM for the arms. The Director of Nursing (DON) stated that the facility's policy required skilled therapy and RNA services for any identified ROM limitations, but this was not followed for Resident 25. The facility's policy indicated that residents with limited ROM should be assessed and provided appropriate treatment and services to prevent further decline, which was not done in this case.
Failure to Provide Required Abuse and Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the appropriate abuse and dementia training. Specifically, CNA 3 did not complete the required pre-test and post-test for elder/dependent adult abuse training, despite having signed the training acknowledgment. Additionally, there was no lesson plan or testing for dementia training, making it impossible to validate the competency of the staff in this area. The Director of Staff Development (DSD) confirmed these deficiencies during an interview and record review, stating that the purpose of the tests was to ensure staff knew the correct answers and to review any incorrect responses. The DSD also acknowledged that the dementia training was part of the orientation process and was essential for understanding resident behavior and interaction, but without proper documentation, the competency could not be verified. The Director of Nursing (DON) also confirmed that the required training for CNAs included two days of orientation and watching dementia and abuse videos. However, the DON was unsure of the exact number of hours required for abuse and dementia training. A review of the facility's policy and procedure (P&P) indicated that CNAs must demonstrate competency in skills necessary to care for residents and that required in-service training must include dementia management and abuse prevention. The failure to complete and document these trainings had the potential to compromise resident safety and well-being.
Failure to Conduct Annual Performance Evaluations for CNA
Penalty
Summary
The facility failed to ensure an annual performance evaluation was performed every year for one Certified Nursing Assistant (CNA). Specifically, CNA 2, who had been working at the facility since 2019, did not receive an employee evaluation for 2023, and another evaluation for 2024 was also due. The Director of Staff Development (DSD) confirmed that staff performance evaluations were supposed to be conducted yearly to measure staff quality of work, knowledge, and skills. The DSD acknowledged that without these evaluations, there was no assessment of CNA 2's quality of work and skills necessary to provide resident care. The Director of Nursing (DON) also confirmed that performance evaluations were reviewed annually to ensure staff were performing well and to identify areas needing improvement. The DON emphasized that without a performance evaluation, staff would not know their competency skills, areas needing improvement, or if further education was needed. The facility's policy and procedure indicated that certified nursing assistants should complete a performance review at least once every 12 months, and regular in-service education should be provided based on these reviews.
Failure to Administer Antibiotics Timely
Penalty
Summary
The facility's nursing staff failed to ensure that a resident received antibiotic medication as prescribed by the physician in a timely manner. The resident, who was diagnosed with acute osteomyelitis, MRSA infection, Type II diabetes, chronic kidney disease, and COPD, had orders for Vancomycin Hydrochloride to be administered intravenously. However, the medication was not administered within the prescribed time frame. Specifically, the Vancomycin 1.5 gm was scheduled for 9:00 a.m. on one date but was given at 3:07 p.m., and the Vancomycin 1 gm was scheduled for 5:00 p.m. on another date but was administered at 7:00 p.m. This delay in administration was confirmed through interviews and record reviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged that the medication should be administered within one hour before or after the scheduled time. The ADON and DON both stated that the IV Medication Administration Record (MAR) should be signed immediately after the medication is given to ensure accuracy. The DON further explained that if the scheduled time for medication passes, the physician should be informed to determine if the medication can still be given or if it should be held. The facility's policy and procedure for medication administration also indicated that medications should be administered within 60 minutes of the scheduled time, and the person administering the medication should record it directly after administration. The failure to adhere to these guidelines resulted in the delayed administration of antibiotics, potentially affecting the effectiveness of the treatment for the resident's MRSA infection in the blood.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,324 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Care Nursing Center | 1.2 mi | ★★★★★ | 6 | 0 |
| Long Beach Healthcare Center | 1.2 mi | ★★★★★ | 8 | 0 |
| Pacific Villa, Inc | 1.2 mi | ★★★★★ | 35 | 0 |
| Bixby Towers Post-acute Rehab | 1.8 mi | ★★★★★ | 6 | 1 |
| Atlantic Memorial Healthcare Center | 1.9 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Beachside Post Acute.
100% money-back within 48 hours.
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.