LONG BEACH, CA - Federal inspectors documented multiple serious health and safety violations at Beachside Post Acute nursing home during an April 2025 survey, including frozen food stored at dangerously elevated temperatures that was still served to residents, improper food handling practices, and critical documentation errors that could have compromised resident care.
Frozen Food Stored at Unsafe Temperatures for Days
The most concerning discovery involved the facility's freezer for frozen vegetables maintaining a temperature of 10 degrees Fahrenheit for at least two days, significantly above the required 0 degrees or below. Despite this known temperature failure, kitchen staff continued using vegetables from the compromised freezer to prepare meals for residents.
During the April 9 inspection, the Dietary Manager confirmed to surveyors that "the kitchen used the vegetables from the non-working freezer for the stir fry vegetables that was served for lunch." The manager acknowledged that residents could be at risk for unsafe food because the vegetables were not properly stored.
A cook interviewed during the inspection stated he had pulled broccoli, carrots, zucchini and cauliflower from the malfunctioning freezer at 4:00 a.m. to prepare for the day's meals. All vegetables served at lunch that day came from the freezer that had been reading 10 degrees Fahrenheit since at least the previous day.
The facility's Registered Dietician revealed the temperature logs might have been falsified, as they showed 0-degree readings for several days when the freezer was actually malfunctioning. The dietician stated that all food items should have been discarded because "the facility does not know how long it had not been working."
Frozen foods must be maintained at 0 degrees Fahrenheit or below to prevent bacterial growth and preserve food quality. When frozen vegetables are stored at 10 degrees, ice crystals form and thaw repeatedly, creating an environment where bacteria can multiply. This temperature abuse can lead to foodborne illnesses, particularly dangerous for elderly nursing home residents with compromised immune systems.
Kitchen Staff Failed to Follow Basic Food Safety Protocols
Inspectors documented multiple instances of kitchen personnel handling ready-to-eat food without gloves during meal service. Staff were observed scooping cooked food items directly from serving trays to resident plates with bare hands during the lunch tray line.
In another incident, a cook donned a glove on one hand without washing hands first, used a microwave in the storage area, then returned to serving food on the tray line without removing the contaminated glove or washing hands. When questioned, the cook admitted he "should have removed his glove and washed hands before serving food in the tray line to prevent cross contamination."
Additionally, an open bag of frozen sausages was found improperly stored in the freezer without being sealed, exposing the food to freezer burn and potential contamination. The sausages showed visible ice crystals on their surfaces, indicating quality degradation from improper storage.
These violations of basic food handling procedures create opportunities for cross-contamination between raw and cooked foods, between contaminated surfaces and ready-to-eat items, and between different food allergens. For nursing home residents, many of whom have weakened immune systems, diabetes, or other conditions that make them more susceptible to foodborne illness, these lapses in food safety can have serious health consequences.
Critical Medical Documentation Errors Affected Resident Care
Beyond food safety issues, inspectors found significant documentation errors that directly impacted resident care. In one case, a resident with a below-knee amputation had medical records incorrectly stating he had an above-knee amputation. This error appeared in multiple assessments over six months, from September 2024 through March 2025.
The distinction between below-knee and above-knee amputation is medically significant. Below-knee amputees retain their knee joint, which provides better mobility options, different rehabilitation needs, and requires assessment of the remaining knee's range of motion. The facility's failure to correctly document this meant the resident's knee joint was never properly assessed for movement limitations.
Physical therapy staff confirmed that incorrect documentation "could affect future assessments and services provided, lead to missed opportunities to identify declines, and result in ROM decline."
In another documentation failure, physician orders for a resident's walking exercises specified using a two-wheeled walker when the resident actually required a platform walker due to limited hand function from hemiplegia. Restorative nursing aides recognized the error and used the correct equipment, but the official medical orders remained incorrect.
The resident affected by this error had severe limitations in both hands and would have been unable to safely grip a standard walker. Using incorrect mobility equipment could have resulted in falls, injuries, or prevented the resident from participating in essential mobility exercises needed to maintain function.
Failure to Properly Assess Veterans with PTSD
The facility also failed to properly screen and assess a military veteran diagnosed with Post-Traumatic Stress Disorder. Despite the resident having served in the military for two years and carrying a PTSD diagnosis, the facility's trauma screening questionnaire incorrectly indicated he had no exposure to combat or traumatic events.
The Director of Social Services acknowledged that because the screening was not properly conducted, the facility could not identify what might trigger the resident's PTSD symptoms or develop an appropriate care plan. Staff members caring for the resident were unaware of his PTSD diagnosis.
For veterans with PTSD, identifying triggers is essential for providing appropriate care and preventing retraumatization. Common triggers in institutional settings can include loud noises, confined spaces, or specific interpersonal interactions. Without proper assessment and care planning, residents with PTSD may experience increased anxiety, behavioral symptoms, or withdrawal from necessary care.
Additional Issues Identified
The inspection also revealed systemic problems with the facility's quality control and oversight systems. Temperature logs for freezers were potentially falsified for multiple days, suggesting a pattern of inadequate monitoring. The Administrator acknowledged that when freezer temperatures exceeded safe levels despite maintenance efforts, all affected food should have been discarded immediately.
The facility's own policies required frozen foods to be stored in airtight, moisture-resistant packaging to prevent freezer burn, yet open bags of frozen items were found improperly stored. Kitchen staff were not following the facility's food handling policy that specifically prohibited bare hand contact with any foods, whether ready-to-eat or in preparation.
Multiple staff members demonstrated awareness of proper procedures during interviews but admitted to not following them in practice. This gap between knowledge and implementation suggests inadequate supervision and enforcement of safety protocols.
Medical Significance of Violations
The temperature abuse of frozen vegetables creates conditions where pathogenic bacteria can multiply to dangerous levels. Common foodborne pathogens like Listeria monocytogenes can grow even at refrigerator temperatures and are particularly dangerous for elderly individuals. Symptoms of foodborne illness in nursing home residents can include severe dehydration from vomiting and diarrhea, which can rapidly become life-threatening in frail elderly populations.
The documentation errors regarding amputation levels and mobility equipment represent more than administrative oversights. Accurate medical documentation drives care planning, insurance coverage determinations, and communication between multiple providers. When documentation fails to reflect a resident's actual condition, it can result in inappropriate treatments, missed opportunities for intervention, and potential injuries from unsuitable equipment or care approaches.
For residents with cognitive impairments or communication difficulties, accurate documentation becomes even more critical as they may be unable to advocate for themselves or correct errors in their care. The facility's pattern of documentation failures suggests systemic issues with quality assurance and staff training that extend beyond individual mistakes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Beachside Post Acute from 2025-04-11 including all violations, facility responses, and corrective action plans.
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