Beach Post-Acute: Hand Hygiene, Food Safety Failures - CA
The January 10 federal inspection at Royal Care Skilled Nursing Center on Pacific Avenue documented multiple infection control failures that put residents at risk for cross-contamination and foodborne illness.
Resident 41, admitted with chronic lung disease, muscle weakness, and a pressure ulcer on the right heel, required extensive help with transfers, dressing, eating, and personal hygiene. During the 1:13 p.m. observation on January 7, LVN 2 performed wound care on the heel ulcer, then used the same gloves to examine a healing wound on the resident's buttocks and cover the patient with bed linens.
The nurse never changed gloves. Never washed hands. Never performed any hand hygiene during or after the wound care procedure.
"She should perform hand hygiene before and after resident care," LVN 2 told inspectors when interviewed two days later.
The following morning, a certified nursing assistant moved between resident rooms without washing her hands after dropping dirty laundry in hallway hampers. CNA 2 wheeled another resident to the dining room without performing hand hygiene between tasks.
"She should perform hand hygiene by using the hand sanitizer and wash her hands, but she forgets because she was rushing out," CNA 2 said during a phone interview on January 10. "It was not a safe practice to not perform hand hygiene."
The facility's infection preventionist warned that staff failures to follow basic hygiene protocols "will put the residents at risk including the staff for the spread of infection and disease."
In the kitchen, inspectors found an open bag of frozen pancakes and cinnamon rolls without date labels at 8:10 a.m. The dietary supervisor confirmed neither item displayed when the package was opened or when the food should be discarded.
"There always needs to be label of open date and use by date on food after it has been opened to ensure the quality of the food was good and palatable for the residents," the dietary supervisor told inspectors.
The director of nursing acknowledged the labeling failure created "a possibility for gastrointestinal illness if residents were served food that was expired."
The facility's own February 2009 food policy required staff to "label and date the food items at the time they are opened, follow the used-by-dates and expiration date on the product."
Beyond basic hygiene failures, inspectors found the facility failed to implement its antibiotic stewardship program for Resident 42, who was prescribed a seven-day course of Augmentin for facial pain without proper assessment.
The resident had left facial pain of unclear cause on December 20, 2024. Progress notes showed the physician "was unable to differentiate if the pain was from a tooth, the jaw, or the cheek" but prescribed the antibiotic "just in case the cause of the pain was from dental or soft tissue."
No bacterial infection was confirmed. No laboratory tests were ordered. The facility's infection preventionist wasn't notified of the antibiotic prescription, violating the facility's stewardship protocols.
"Before antibiotics were given to residents an assessment should be done by the licensed nurse, the physician orders labs, and the results of the labs are reviewed by the doctor," the infection preventionist explained. She said she reviews specific clinical criteria to determine if residents actually need antibiotics, but "Resident 42 did not have an assessment documented, and labs were not ordered."
The resident was referred to a dentist on December 27 but discharged before the appointment.
"When the McGeer criteria or Loeb criteria was not used prior to antibiotic used, residents can become resistant to antibiotics, the resident could be taken antibiotics unnecessarily, or the resident could be taking the wrong antibiotic," the infection preventionist said.
The facility's June 2023 antibiotic stewardship policy required nursing staff to assess suspected infections before contacting physicians and specified that laboratory testing should follow current standards. The policy mandated use of McGeer criteria to define infections and Loeb criteria to determine antibiotic necessity.
The registered nurse supervisor confirmed that licensed nurses must notify the infection preventionist of all antibiotic orders for proper stewardship review. "If Antibiotic Stewardship was not done the resident could develop resistance to the antibiotic and the resident will be hard to treat with antibiotic if the resident gets an infection."
Vaccination education also fell short. Two residents — 42 and 71 — refused influenza, pneumonia, and COVID-19 vaccines without receiving required education about the risks and benefits of their decisions.
Resident 42, diagnosed with hepatitis C, asthma, and schizophrenia, had intact cognition according to assessment records but lacked decision-making capacity according to physician notes. Resident 71, with bone infection, diabetes, and morbid obesity, had moderate cognitive impairment.
Both residents' immunization records from December showed vaccine refusals without documentation of educational discussions.
"It was important with these resident population that we make sure they were informed and educated on the risks and benefits of refusing vaccines," the infection preventionist said. She could not find clinical record evidence that either resident received required education.
The director of nursing confirmed awareness that both residents lacked documentation of vaccine education discussions. "When the resident refuses to get a vaccine the nurses should educate the resident on the risk and benefits of refusing and document in the clinical record, that the resident knows the importance of getting vaccinated."
The facility's infection control policy, revised in October 2022, specifically required education about vaccine benefits and side effects before offering immunizations. The policy stated that documentation must reflect both the education provided and vaccination decisions.
These violations placed vulnerable residents at higher risk for acquiring and transmitting preventable diseases to other immunocompromised patients in the facility.
The inspection revealed a pattern of staff rushing through basic safety protocols. The certified nursing assistant admitted forgetting hand hygiene because she was "rushing out." The infection preventionist wasn't notified of antibiotic prescriptions. Vaccine education went undocumented.
Royal Care Skilled Nursing Center's failures spanned the most fundamental aspects of resident safety — clean hands, safe food, appropriate medications, and informed healthcare decisions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Beach Post-acute from 2025-01-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
The Beach Post-Acute in LONG BEACH, CA was cited for violations during a health inspection on January 10, 2025.
The nurse never changed gloves.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.