Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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.
Dishwasher Temperature Gauge Not Functioning Properly: The facility failed to ensure the kitchen dishwasher temperature gauge was working properly. A DA observed the gauge showing one temperature while a photo showed a lower reading, and another DA later stated the gauge had not been working and had been broken since the prior day. The Dietary Supervisor confirmed the gauge was broken, and the DON stated the gauge needed to be functional to ensure proper dish sanitization.
Missed Quarterly Joint Mobility Screens for Multiple Residents The facility failed to complete required quarterly JMS for several residents with ROM limitations or risk for decline. Residents with diagnoses including hemiplegia, hemiparesis, contractures, and metabolic encephalopathy had MDS findings showing severe cognitive impairment and dependence for multiple ADLs, and care plans included restorative nursing programs, splints, and ROM interventions. The DOR confirmed that quarterly JMS were missed for residents who should have been monitored under the facility’s revised rehab screening policy.
Failure to Notify Physician of Low BP: A resident with HTN, HF, and DM had multiple low BP readings while on a care plan for fluctuating BP, but nursing staff did not document an SBAR, did not record a change of condition, and did not notify the physician. Interviews with the LPN, RNS, and DON confirmed the lack of assessment and provider notification.
Failure to Include Toenail Fungus in Care Plan: A resident with severely impaired cognition and max assist needs had podiatry-documented onychomycosis and onychodystrophy, with yellow, crusty, thick toenails noted on all 10 toes. Staff, including an LVN, RNS, and DON, confirmed there was no care plan addressing the toenail fungus, and the condition was not included in the resident’s comprehensive care plan.
Failure to initiate a COC for a resident with left shoulder pain. A resident with dementia and severe cognitive impairment was started on diclofenac gel for pain, but staff observed him rubbing his shoulder and stating the cream was not working and he needed something stronger. An LVN and the DON both confirmed no COC was completed when the new pain medication was started, despite the need to monitor whether it was effective and tolerated.
Two residents experienced medication administration errors. One resident had lidocaine patches left on beyond the scheduled removal time, and the MAR was documented as removed before the patches were actually taken off. Another resident had an order for spironolactone to be held if SBP was below 110 mmHg, with records showing the resident had HTN, HF, and DM and was at risk for hypotension, but the blood pressure review was incomplete in the excerpt provided.
Gas Hose Leaks in Laundry Room: The facility failed to ensure the two dryer gas hoses were intact and free from leaks. Staff observed a strong pungent odor in the laundry room, and the ADM later confirmed the gas company found minimal leaks in three areas of the hoses connected to the dryers. The MS stated the leak was in the dryer hoses, not the main gas line, and the facility policy on Natural Gas Emergencies did not include procedures to prevent or monitor for a potential gas leak.
A resident with dementia, osteoporosis, and limited mobility sustained an acute distal femur fracture of unknown cause. The facility became aware of the injury through X-ray results but did not report the unusual occurrence to CDPH within the required 24-hour timeframe, as confirmed by staff interviews and record review. This delay was not in accordance with facility policy for reporting injuries of unknown origin.
The facility's kitchen staff, including a dietary supervisor assistant and a dietary aide, failed to follow proper food thawing procedures, leading to a deficiency. A box of chicken was improperly thawed and refrozen, contrary to facility policy and FDA guidelines. This placed 99 out of 106 residents at risk for foodborne illness due to potential bacterial growth.
The facility failed to maintain sanitary food storage and handling practices, risking foodborne illnesses for residents. Observations included expired cottage cheese, incomplete temperature logs, and improper thawing and refreezing of food. Additionally, the ice machine was inadequately cleaned, with no cleaning log maintained, increasing the risk of contamination.
A facility failed to maintain accurate and complete clinical documentation for two residents. One resident's records inaccurately documented IV access and fluids, despite observations confirming the absence of IV access. Another resident's records were incomplete regarding Restorative Nursing Aide services, with a missing RNA flow sheet. These deficiencies highlight a failure to adhere to documentation standards, potentially impacting resident care.
The facility failed to implement proper infection control measures, as evidenced by improper PPE use and maintenance of equipment. A resident on Enhanced Barrier Precautions (EBP) had a visitor not wearing PPE, and staff did not follow proper PPE protocols, increasing the risk of infection spread. Additionally, padded side rails on beds were inadequately maintained, with cracked duct tape exposing foam, compromising disinfection efforts.
A resident with a history of amputation, muscle weakness, and dependence on supplemental oxygen was found in a state of anxiety and hyperventilation due to difficulty breathing. The call light was out of reach, preventing the resident from calling for help as her oxygen supply was running low. Facility staff confirmed that the call light should have been within reach, as per the facility's policy and the resident's care plan.
A facility failed to monitor a resident's range of motion (ROM) in both legs by not performing an annual Joint Mobility Screen (JMS) as per policy, potentially leaving the resident without proper monitoring for 21 months. The resident had impaired ROM in hips, knees, and ankles, and the PT discharge recommended PROM exercises. However, the JMS did not assess the legs, leading to a gap in monitoring. Interviews confirmed the JMS was meant to track ROM decline and prevent complications, but the facility did not adhere to its policy.
A resident in hospice care with dementia and other conditions lost their dentures, and the facility failed to provide prompt dental services or adjust the diet to ensure adequate nutrition. Despite significant weight loss and poor oral intake, the resident's diet remained unchanged, and there was a lack of communication among staff regarding the resident's needs. The facility's policy for prompt dental referral was not effectively implemented.
A resident in hospice care with dementia and other conditions was not provided with her preferred puree diet, despite her inability to consume solid foods. The facility's staff, including CNAs and an LVN, were aware of her preference but failed to communicate this to the RD or update her care plan. The DON was also unaware of the resident's needs, which led to inadequate dietary accommodations.
A resident with dementia and osteoporosis sustained a femur fracture of unknown origin, which was not reported to the CDPH as required by facility policy. The DON did not report the injury, believing it was unavoidable due to the resident's condition. The Administrator later acknowledged the reporting failure, which hindered timely investigation by CDPH.
A resident with dementia and osteoporosis sustained a femur fracture of unknown origin, which was not investigated by the facility. Despite the resident's physician attributing the fracture to osteoporosis, the facility's policy required an investigation for injuries of unknown origin. The administrator acknowledged the need for an investigation to determine the root cause.
Dishwasher Temperature Gauge Not Functioning Properly
Penalty
Summary
The facility failed to ensure the kitchen dishwasher temperature gauge was functioning properly. During a concurrent observation and interview in the kitchen, a low-temperature dishwasher was being used to wash dishes, and Dietary Aide (DA) 1 stated the wash temperature gauge displayed 120 degrees Fahrenheit; however, a photo taken at that time showed the gauge reading 95 degrees Fahrenheit. During a later interview, DA 2 ran a dishwasher cycle and stated the temperature gauge displayed 110 degrees Fahrenheit, and DA 2 stated the gauge had not been working since 12/15/2025. During a subsequent interview, DA 1 stated the dishwasher temperature gauge had been broken since 12/15/2025 and admitted she had been nervous and provided an inaccurate temperature reading during the earlier observation. The Dietary Supervisor stated she contacted maintenance because the dishwasher temperature gauge was broken and the wash cycle readings were above 130 degrees Fahrenheit, and confirmed the gauge was broken while the facility waited for replacement parts. The DON stated the dishwasher temperature gauge needed to be functional to ensure the correct temperatures were reached to kill germs or microbes and to sanitize dishes.
Missed Quarterly Joint Mobility Screens
Penalty
Summary
The facility failed to complete required quarterly Joint Mobility Screens (JMS) for four sampled residents who had or were at risk for limited ROM and mobility. The deficiency involved Residents 58, 15, 38, and 52, and the report states that the missed JMS were in 5/2025 and 8/2025 for Resident 58, 7/2025 for Residents 15 and 38, and 5/2025 for Resident 52. The facility’s policy revised in May 2025 required joint mobility assessments to be completed quarterly, annually, and as needed to identify residents with functional changes and/or changes in ROM. Resident 58 was admitted and readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction and Type 2 diabetes mellitus. The resident’s MDS showed severe cognitive impairment, partial assistance with some ADLs, substantial assistance with bathing, lower body dressing, sit-to-stand, and chair-to-bed transfers, and supervision for walking 50 feet. The MDS also documented functional ROM limitations in both upper extremities. The care plan identified a restorative ambulation program and risk for decline in ambulation, falls, and impaired safety judgment. A JMS completed on 11/4/2025 showed full ROM in both upper and lower extremities, and the DOR stated there were no other JMS completed for Resident 58 in 2025 despite the quarterly schedule. Resident 38 was admitted and readmitted with diagnoses including metabolic encephalopathy, contracture of the left knee, and acute respiratory failure with hypoxia. The resident’s H&P stated the resident did not have capacity to understand and make decisions, and the MDS showed severe cognitive impairment, dependent assistance for oral hygiene, bathing, dressing, rolling, and bed-to-chair transfers, and functional ROM limitations in both upper and lower extremities. The care plan included a restorative splinting program with multiple splints and hand rolls, and the JMS dated 10/2/2025 documented severe and moderate ROM losses in multiple joints with a recommendation for an RNA program. During observation, the resident was seen in bed wearing splints and with both elbows and knees bent. The DOR stated there were no other quarterly JMS completed for Resident 38 in 2025, and that the July 2025 quarterly JMS was missed. Resident 52 was admitted and readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, contracture of the right elbow, and contracture of the right hand. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed severe cognitive impairment, dependent assistance for oral hygiene, bathing, dressing, rolling, and bed-to-chair transfers, and functional ROM limitations in both upper and lower extremities. The care plan included a therapeutic exercise/ROM restorative nursing program with AAROM and PROM interventions. JMS completed on 2/28/2025 and 10/16/2025 documented ROM findings and recommendations for RNA services, but the DOR stated the May 2025 quarterly JMS was not completed. The report also states Resident 15 did not receive a quarterly JMS in 7/2025, but no additional resident-specific details were provided in the narrative.
Failure to Notify Physician of Resident’s Low Blood Pressure
Penalty
Summary
The facility failed to ensure Resident 113 was assessed and that the physician was notified when the resident experienced a significant change of condition related to low blood pressure. Resident 113 was admitted and later readmitted with diagnoses including HTN, heart failure, and DM. The care plan for hypertension, revised 11/19/2025, identified the resident as at risk for fluctuating blood pressure and directed staff to monitor, document, and report side effects such as orthostatic hypotension. The MDS dated 11/28/2025 indicated the resident could express ideas and wants, usually understood verbal content, and was dependent on nursing staff for eating, oral hygiene, toileting, showering, dressing, and transferring. A review of blood pressure readings from 11/26/2025 through 11/28/2025 showed multiple low readings, including 90/62 mmHg, 94/62 mmHg, 100/66 mmHg, 108/64 mmHg, 104/66 mmHg, 99/72 mmHg, and 100/70 mmHg. During interview and record review, LVN 2 stated licensed nursing staff should immediately notify the physician if systolic blood pressure was below 110 or diastolic blood pressure was below 90, and that an SBAR should be documented for low blood pressure. LVN 2, RNS 2, and the DON stated there was no documentation of an SBAR, no documentation of a change of condition, and the physician was not notified. The DON stated the resident's blood pressure should have been reassessed and the physician should have been notified.
Failure to Include Toenail Fungus in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for one sampled resident by not addressing the resident’s toenail fungus in the care plan. Resident 18 was admitted with diagnoses including bipolar disorder and osteoarthritis, and the MDS dated 11/6/2025 indicated severely impaired cognition and maximum assistance needed with toileting and showering. A podiatrist note dated 10/23/2025 documented onychomycosis and onychodystrophy, and during an observation on 12/16/2025, Resident 18 was noted to have yellow, crusty, thick toenails on all 10 toes. During interviews and record review, LVN 4 stated she was familiar with Resident 18 but was not aware of the toenail fungus and confirmed there was no care plan addressing the condition. RNS 2 reviewed the podiatrist notes and confirmed the resident had onychomycosis, stating there should be a care plan in place for the condition so staff can monitor and assess for improvement or worsening. The DON stated care plans address problems with goals, interventions, and monitoring for improvement, and stated there should be a care plan in place for Resident 18’s toenail fungus.
Failure to Initiate Change of Condition for Resident Pain
Penalty
Summary
Safe, appropriate pain management was not provided for a resident who reported left shoulder pain. Resident 106 was admitted with diagnoses including encephalopathy, anemia, and dementia. The resident’s H&P dated 8/22/2025 described him as alert and oriented, while the MDS dated 11/26/2025 indicated severe cognitive impairment and that he needed setup or clean up assistance with ADLs. The order summary showed diclofenac sodium 1% external gel was started on 12/11/2025 for pain management to the neck, left upper shoulder, and right upper shoulder. During an observation and interview on 12/16/2025, Resident 106 was seen rubbing his left shoulder and stated his shoulder was hurting bad, that the cream being applied was not working, and that he needed something stronger. An LVN later stated that a change of condition should have been initiated when the resident was experiencing pain and a new medication was started, and that no COC was documented when diclofenac was begun. The DON also confirmed that no COC was completed and stated it should have been initiated to ensure the resident was tolerating the medication and that it was effective in managing pain. The care plan noted the resident was receiving diclofenac gel as ordered and included interventions to monitor and document the probable cause of each pain episode.
Medication administration errors involving lidocaine patch removal and held spironolactone order
Penalty
Summary
The facility failed to ensure two sampled residents were free from significant medication errors. For Resident 84, the physician order dated 7/1/2025 directed lidocaine 5% external patches to be applied to both knees once daily for pain management and removed per schedule. During an observation on 12/18/2025 at 8:06 a.m., Resident 84 had lidocaine patches on both knees dated 12/17/2025, and LVN 1 removed the old patches and applied new ones. During a concurrent interview and record review, the MAR showed the patches were documented as removed at 9:00 p.m. on 12/17/2025, but LVN 1 stated the nurse documented the removal without actually removing the patches. Resident 84’s record showed admission on 12/13/2024 and readmission with diagnoses including cellulitis of the left upper limb, pain in the left wrist, pain in the right leg, and lumbar intervertebral disc degeneration with lower extremity pain. The H&P dated 12/14/2024 indicated the resident had the capacity to understand and make decisions, while the MDS dated 9/16/2025 indicated severe problems with thinking and memory and dependence or assistance with several activities of daily living. LVN 3 stated she should not have clicked the MAR to document removal before removing the patches, and the DON stated lidocaine patches should be removed by the afternoon shift per the physician’s order. For Resident 113, the order summary dated 11/15/2025 showed spironolactone 25 mg by mouth in the morning for heart failure, to be held if systolic blood pressure was less than 110 mmHg. The resident’s record showed diagnoses including HTN, heart failure, and DM. The care plan identified the resident as at risk for fluctuating blood pressure and hypotension, with monitoring for adverse effects such as dizziness, postural hypotension, fatigue, and increased fall risk. The MDS dated 11/28/2025 indicated the resident could express ideas and wants, usually understood verbal content, and was dependent on nursing staff for multiple activities of daily living. The report states that the resident’s blood pressure readings dated 11/26/2025, 11/27/2025, and 11/28/2025 were reviewed, but the excerpt provided ends before listing the actual readings.
Gas Hose Leaks in Laundry Room
Penalty
Summary
The facility failed to ensure that the two dryers’ gas hoses connected to the gas line were intact and free from leaks. During a concurrent observation and interview in the laundry room, a strong pungent distinct odor was noted. A Laundry Aid stated she did not smell any odor different from the chemicals used for laundering, while the Administrator stated she smelled a slight gas-like odor in the laundry room. The Administrator later stated the gas company was contacted and found minimal leaks in three different areas of the hoses connected to the dryers prior to the gas shut off valve connected to the gas line. The Maintenance Supervisor stated the leak was on the hoses connected to the dryers and not the main gas line, and that he turned off the gas because he was not certified and did not have the tools to test for gas leaks. Review of the facility’s Natural Gas Emergencies policy dated 12/22/2023 showed it did not include procedures to prevent and monitor for a potential gas leak in the facility.
Failure to Timely Report Unexplained Fracture to State Agency
Penalty
Summary
The facility failed to follow its abuse prevention and unusual occurrence reporting policies when it did not report an acute, new distal femur fracture of unknown cause for a resident to the State Survey Agency (CDPH) within 24 hours of becoming aware of the incident. The resident, who had diagnoses including age-related osteoporosis, dementia, and right knee contracture, was dependent on assistance for activities of daily living and lacked capacity to make decisions. The fracture was identified via X-ray, and the results were reported to the facility on 5/4/2025. However, the facility did not notify CDPH of the unusual occurrence until 5/7/2025, exceeding the required 24-hour reporting timeframe. Interviews with facility staff, including the RN Supervisor and DON, confirmed that the delay in reporting was not in accordance with facility policy, which requires reporting of such incidents within 24 hours. Review of the facility's policies further supported that all unusual occurrences and injuries of unknown origin must be reported promptly to appropriate authorities. The failure to report the incident in a timely manner was acknowledged by staff and documented in the facility's records.
Improper Thawing Practices in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff, including the dietary supervisor assistant (DSA) and dietary aide (DA 1), were competent in following the facility's food thawing policies. During an observation, a box of frozen chicken was found sitting by the food preparation sink, appearing partially thawed with wet cardboard from thawing juices. The DSA instructed DA 1 to place the chicken back into the main freezer, which was against the facility's policy. Later, the DSA instructed staff to remove the chicken from the freezer and place it back in the sink for thawing, initially without running water, which was also against the policy. The dietary supervisor (DS) later intervened, stating that refreezing chicken was not allowed. Interviews with DA 1 and the DSA revealed a lack of understanding of proper thawing procedures, as DA 1 followed the DSA's incorrect instructions despite knowing they were wrong. The facility's policies indicated that food should not be thawed at room temperature and should be submerged in cold running water. The U.S. Food and Drug Administration food code was also referenced, highlighting the risks of improper thawing, which can lead to bacterial growth and foodborne illness. This deficiency placed 99 out of 106 residents at risk for developing foodborne illnesses.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to the growth of microorganisms and potential foodborne illnesses for 99 out of 106 residents. Observations revealed that cottage cheese in the reach-in refrigerator was past its use-by date, and the temperature log for the walk-in refrigerator was not consistently filled out. Additionally, improper food handling practices were noted, such as thawed frozen waffles being returned to the freezer and raw chicken being improperly thawed and refrozen. The dietary staff did not adhere to proper thawing techniques, as evidenced by chicken being left to thaw in a sink without running water. The dietary supervisor assistant instructed staff to refreeze partially thawed chicken, which was against facility procedures. The dietary supervisor later confirmed that thawed items should not be refrozen and should be placed in the refrigerator to continue thawing. These practices increased the risk of bacterial growth and potential food contamination. The facility's ice machine was also found to be inadequately maintained, with dust and a black substance observed in the upper portion. The maintenance supervisor admitted to cleaning the ice machine every six months but did not keep a cleaning log. The infection preventionist nurse highlighted the potential risk of illness due to the unclean ice machine. The facility's policies and procedures, as well as the U.S. Food and Drug Administration food code, were not followed, contributing to the deficiencies observed.
Inaccurate and Incomplete Clinical Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation for two residents, leading to deficiencies in their care records. For one resident, the documentation related to intravenous (IV) access and fluids was inaccurate. The resident was admitted with severe cognitive impairment and conditions such as seizures and acute kidney failure. Despite physician orders indicating the completion of IV fluids on a specific date, subsequent notes inaccurately documented the resident as still receiving IV fluids. Observations confirmed the absence of IV access, and interviews with nursing staff revealed the documentation errors, highlighting the importance of accurate records to prevent infection risks and ensure proper hydration assessment. Another resident with limited range of motion and mobility issues had incomplete clinical records regarding the provision of Restorative Nursing Aide (RNA) services. The resident, diagnosed with dementia and functional quadriplegia, required passive range of motion exercises and the application of splints as per physician orders. However, the RNA flow sheet for a specific month was missing from the resident's clinical record. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed the absence of the flow sheet, indicating incomplete records for the resident's RNA services. The facility's policy and procedure on charting and documentation emphasized the need for complete and accurate medical records for all services provided to residents. The deficiencies in documentation for both residents reflect a failure to adhere to these standards, resulting in incomplete and inaccurate clinical records. This lack of proper documentation could potentially impact the quality of care provided to the residents.
Infection Control Deficiencies in PPE Use and Equipment Maintenance
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by several observations and interviews. In the case of Resident 260, who was on Enhanced Barrier Precautions (EBP) due to a gastrostomy and an unstageable pressure ulcer, a visitor was observed not wearing the required Personal Protective Equipment (PPE) while interacting with the resident. Licensed Vocational Nurses (LVN) 2 and 3, who attended to Resident 260, did not instruct the visitor to wear PPE and were observed doffing their PPE incorrectly, potentially leading to self-contamination. The facility's policy and CDC guidelines were not followed, as gloves were not removed first, which is crucial to prevent the spread of infection. In another instance, Resident 8, who was also on EBP due to a gastrostomy and stage 3 pressure ulcer, received care from LVN 1, LVN 4, and CNA 1, none of whom wore the appropriate PPE. LVN 1 and CNA 1 entered the room and provided care without donning any PPE, while LVN 4 only wore gloves. This lack of adherence to PPE protocols during high-contact care activities increased the risk of cross-contamination and infection spread among residents and staff. Additionally, the facility failed to maintain the integrity of padded side rails on the beds of four residents, which were covered with duct tape that was cracked and peeling, exposing the foam underneath. This compromised the ability to properly disinfect the side rails, as the foam is a porous material that cannot be sanitized effectively. The maintenance supervisor acknowledged the issue, stating that the duct tape was used as a temporary measure, but it was not recommended by the bed manufacturer. The housekeeping supervisor confirmed that the exposed foam posed a risk for bacterial growth, as the disinfectant used was only effective on hard, non-porous surfaces.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was within reach for Resident 8, which had the potential to prevent the resident from receiving necessary care and services in a timely manner. Resident 8, who had a history of left leg above knee amputation, muscle weakness, dependence on supplemental oxygen, and a stage 3 pressure ulcer, was observed sitting in a wheelchair and experiencing hyperventilation and anxiety due to difficulty breathing. The call light was clipped on the left side of the bed, out of reach for Resident 8, who expressed fear and helplessness due to her inability to call for help as her oxygen supply was running low. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, confirmed that the call light should have been within reach at all times to accommodate residents' needs promptly. The facility's policy and procedure on answering call lights also indicated that the call light should be within easy reach of residents. Resident 8's care plan, which highlighted her risk for falls and impaired balance, also specified that the call light should be kept within easy reach, yet this was not adhered to, leading to the deficiency.
Failure to Monitor Resident's Range of Motion
Penalty
Summary
The facility failed to monitor the range of motion (ROM) in both legs of a resident with limited mobility, as they did not perform an annual Joint Mobility Screen (JMS) on the specified date in accordance with their policy. This oversight potentially left the resident without proper monitoring for 21 months, from the discharge from Physical Therapy (PT) to the next scheduled JMS. The resident, who was initially admitted in 2019 and readmitted in 2023, had diagnoses including dementia, functional quadriplegia, and contractures in multiple joints. The resident's PT evaluation in July 2023 indicated impaired ROM in both hips, knees, and ankles, with specific limitations noted in hip flexion, knee flexion, and ankle dorsiflexion and plantarflexion. The PT discharge summary recommended passive range of motion (PROM) exercises for both legs, except the right knee, to be performed by a Restorative Nursing Aide (RNA) five times per week. However, the annual JMS conducted in April 2024 did not assess the ROM in the resident's legs, leaving a gap in monitoring. Interviews with the Director of Rehabilitation (DOR) and the Director of Nursing (DON) confirmed that the JMS was intended to track ROM decline and prevent complications such as contractures and pressure injuries. The facility's policy required annual JMS for each resident, but the resident's legs were not assessed since the PT discharge, leading to a prolonged period without evaluation. The facility's policy and procedure indicated that residents with limited ROM should receive appropriate services to maintain or improve mobility, which was not adhered to in this case.
Failure to Provide Prompt Dental Services and Adequate Nutrition
Penalty
Summary
The facility failed to provide prompt dental services for a resident after the loss of dentures on 9/10/24. The resident, who was admitted under hospice care with multiple diagnoses including dementia and heart failure, was dependent on assistance for daily activities and had a mechanical soft diet ordered. Despite the loss of dentures, there was no dental consult ordered immediately, and the resident did not receive a dental evaluation until 9/25/24. During this period, the resident was unable to eat the mechanical soft diet adequately, leading to poor oral intake and significant weight loss. The facility's records indicate that the resident was referred to a dentist on 9/11/24, but the dental progress notes show that no treatment was indicated due to the resident's medical condition. The resident's diet remained unchanged despite the inability to chew properly, and there was no documentation of any interventions to ensure adequate nutrition. The interdisciplinary team discussed the resident's condition on 10/16/24, noting the weight loss, but did not adjust the diet consistency. Interviews with staff revealed a lack of communication and coordination regarding the resident's dietary needs and dental status. The Registered Dietitian was not informed of the denture loss and thus did not adjust the diet to a puree consistency, which could have been more suitable given the resident's inability to chew. The Director of Nursing was aware of the denture loss but did not initiate a change in diet consistency. The facility's policy required prompt referral to a dentist for lost dentures, but this was not effectively implemented, resulting in a delay in addressing the resident's nutritional needs.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident received food according to her preferences, which led to a deficiency in care. The resident, who was admitted under hospice care with multiple diagnoses including dementia and heart failure, was on a mechanical soft diet. However, it was observed that she preferred puree food, as she had no teeth and struggled with solid foods. Despite this preference, there was no discussion or action taken to change her diet to accommodate her needs. During observations and interviews, it was noted that the resident ate very little of her meals, consuming only about 25% of her food intake. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) both acknowledged the resident's preference for puree food, yet this information was not communicated to the Registered Dietitian (RD) or reflected in the resident's care plan. The RD stated that if they had been informed of the resident's chewing difficulties, they would have downgraded the diet to a puree consistency to prevent the risk of weight loss. The Director of Nursing (DON) was unaware of the resident's dietary preferences and stated that a Speech Language Pathologist (SLP) would have been consulted to evaluate the resident if this information had been known. The facility's policy on resident food preferences requires staff to document dietary preferences and communicate any conflicts with therapeutic diets, but this was not adhered to in the case of this resident.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for a resident who sustained a moderately displaced fracture of the distal diaphysis of the femur. The resident, who was admitted with diagnoses including encephalopathy, dementia, and generalized weakness, was unable to make consistent and reasonable decisions. On a specific date, the resident was noted to be groaning and screaming during assistance with lower body dressing, and swelling was observed in the right knee. A stat X-ray revealed a moderately displaced fracture, and the resident was subsequently transferred to a General Acute Care Hospital for evaluation and treatment. The Director of Nursing Services (DON) did not report the injury to CDPH, citing the physician's documentation that the fracture was unavoidable due to the resident's osteoporosis. However, the facility's policy requires that any injury of unknown source be reported immediately to the Administrator and state officials. The Administrator acknowledged that the facility should have reported the injury to CDPH. This oversight resulted in the inability of CDPH to investigate the injury in a timely manner, potentially leading to the loss of relevant facts related to the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who sustained a moderately displaced fracture of the distal diaphysis of the femur. The resident, who was admitted with diagnoses including encephalopathy, dementia, and generalized weakness, was unable to make consistent and reasonable decisions. On a specific date, the resident was noted to be groaning and screaming during assistance with lower body dressing, and swelling was observed in the right knee. A stat X-ray revealed the fracture, and the resident was subsequently transferred to a general acute care hospital for evaluation and treatment. The Director of Nursing Services did not investigate the injury, citing the resident's osteoporosis as the reason for the fracture being deemed unavoidable by the resident's physician. However, the facility's policy and procedure for reporting and investigating abuse, neglect, exploitation, or misappropriation, revised in April 2021, mandates that all reports of resident abuse, including injuries of unknown origin, are thoroughly investigated by facility management. The facility's administrator acknowledged that an investigation should have been conducted to determine the root cause of the injury.
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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 Torrance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Torrance Memorial Med Ctr Snf/dp | 0.8 mi | ★★★★★ | 3 | 0 |
| Del Amo Gardens Care Center | 1.2 mi | ★★★★★ | 14 | 0 |
| Bay Crest Care Center | 1.5 mi | ★★★★★ | 49 | 1 |
| Torrance Care Center West, Inc | 1.5 mi | ★★★★★ | 7 | 0 |
| Providence Little Co Of Mary Transitional Care Ctr | 1.6 mi | ★★★★★ | 17 | 0 |
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