Beachside Post Acute

F-F726

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 49145

Residents Affected - Few Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification.

This deficient practice resulted in the facility to have repeat deficiencies in comprehensive resident centered care plans, competent nursing staff, safe operating equipment, and the prevention of a decrease in range of motion (ROM- full movement potential of a joint).

Findings:

During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies in comprehensive resident centered care plans, competent nursing staff, safe operating equipment, and the prevention of a decrease in range of motion (ROM).

During a concurrent interview and record review on 4/11/2025 at with the Director of Nursing (DON), the DON stated she will continue to work on and make further changes for the issues that were still areas of concerns. The DON stated they need to improve their care plan process, increase the frequency for monitoring of equipment, ensure the staff are responsible and being held accountable when checking the freezer temperatures, and increase staff education regarding ROM by providing in-services for the licensed nurses performing the ROM exercises.

During a review of the facility's policy and procedure (P&P) titled, Quality Assurance Performance Improvement Committee (QAPI), dated 1/2017, the P&P indicated, The purpose of the QAPI committee is to provide a systematic self-evaluation process to identify and resolve problems. Input from regulatory agencies and consultants will be integrated in the QAPI committee review process (i.e. survey, complaint visits). The committee is responsible for overseeing the entire quality improvement program. It identifies and prioritizes issues for QAPI evaluation and aspects of care and monitors implementation of action plans recommended.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49145 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain and observe infection Residents Affected - Some control practices by failing to:

a.Change and label tube feeding water bag for Resident 28.

b.Perform hand hygiene during wound care dressing change for Resident 56.

c.Ensure Physical Therapist 1 (PT 1) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assessing Resident 14's left leg which required direct contact with Resident 14 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed reduce the transmission of multi-drug-resistant organisms).

d. Licensed Vocational Nurse (LVN) 5 failed to sanitize blood pressure cuff in between residents.

e. Ensure sanitary handling and transport of soiled linens.

These deficient practice had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection.

Findings:

a. During a review of Resident 28's Admission Record, the Admission Record indicated Resident 28 was admitted to the facility on [DATE REDACTED] with diagnoses including hypertension ([HTN]- high blood pressure) and hemiplegia (weakness on one side of the body).

During a review of Resident 28's Minimum Data Set ([MDS]- a resident assessment tool) dated 3/18/2025,

the MDS indicated Resident 28 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 28 required maximal assistant with Activities of Daily Living ([ADL]- activities such as bathing, dressing, and toileting a person performs daily).

During a concurrent observation and interview on 4/8/2025 at 10:42 a.m., with Licensed Vocational Nurse (LVN) 1 in Resident 28's room, LVN 1 stated Resident 28's tube feeding water bag was not labeled of date change and was unable to determine when it was changed. LVN 1 stated it was important to change and label the tube feeding water bags daily for infection control.

During an interview on 4/11/2025 at 1:55 p.m., with the Infection Prevention Nurse (IPN), the IPN stated tube feeding water bags should be changed and labeled with date change daily to prevent the growth of bacteria which can cause the resident to develop stomach issues.

During an interview on 4/11/2025 at 2:47 p.m., with the Director of Nursing (DON), the DON stated tube feeding water bags should be changed and labeled with changed date every 24 hours to prevent spoilage, stomach issues, and infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 b. During a review of Resident 56's Admission Record, the Admission Record indicated Resident 56 was admitted to the facility on [DATE REDACTED] with diagnoses including Parkinson's disease (a progressive disease of the Level of Harm - Minimal harm or nervous system marker by tremor, muscular rigidity, and slow, imprecise movement) and dementia (a potential for actual harm progressive state of decline in mental abilities).

Residents Affected - Some During a review of Resident 56's MDS dated [DATE REDACTED], the MDS indicated Resident 56 had severe cognitive impairment and was dependent (helper does all the effort) with ADL's.

During an observation on 4/10/2025 at 11:11 a.m., in Resident 56's room, LVN 1 was observed changing a wound dressing without performing hand hygiene after removing the soiled wound dressing and cleaning the site and before applying the clean wound dressing.

During an interview on 4/10/2025 at 11:23 a.m., with LVN 1, LVN 1 stated he did not perform hand hygiene

after handling the soiled dressing and before applying the clean dressing to Resident 56's wound. LVN 1 stated he should have performed hand hygiene for infection control and failure to perform hand hygiene had

the potential for spread of infection.

During a interview on 4/11/2025 at 2:01 p.m., with the IPN, the IPN stated hand hygiene should be performed in between removing the soiled dressing and applying the clean dressing when doing a wound care dressing change. LVN 1 stated hand hygiene was important to do to prevent infection and contamination of the wound which could potentially lead to an infection of the wound.

During a continued interview on 4/11/2025 at 2:47 p.m., with the DON, the DON stated hand hygiene should be performed before, after removing the dirty dressing, and before applying the clean dressing to prevent contamination and infection.

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c. During a review of Resident 14's Admission Record, the Admission Record indicated Resident 14 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of

the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of

the nerves that can cause weakness, numbness, and burning pain).

During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury)

in both legs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a concurrent observation and interview on 4/10/2025 at 2:24 pm, with PT 1 in Resident 14's room, observed Resident 14 lying in bed. PT 1 entered Resident 14's room, put on gloves, and did not put on an Level of Harm - Minimal harm or isolation gown. PT 1 walked to Resident 14's bed, picked up Resident 14's left leg, asked Resident 14 to potential for actual harm bend his left knee, and put Resident 14's leg back onto the bed. After completing assessment of Resident 14's left leg, PT 1 removed both gloves, exited the room, and used alcohol-based hand sanitizer. PT 1 stated Residents Affected - Some he did not wear an isolation gown while providing direct care to Resident 14. PT 1 stated he should have worn an isolation gown while assessing Resident 14's left leg because he had direct contact with Resident 14 who was on EBP precautions. PT 1 stated it was important to follow infection control protocols to prevent

the spread of infection.

During an interview on 4/10/2025 at 3:04 pm, the IPN stated the purpose of EBP was to minimize the risk of infection for residents with invasive devices (medical tools that enter the body either through a break in the skin or an opening in the body) such as foley catheters (thin, flexible rube inserted into the bladder to drain urine), gastronomy tubes (a tube placed directly into the stomach for long-term feeding), and open, non-healing wounds. The IPN stated all staff providing direct patient care for residents on EBP precautions must wear the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) which included an isolation gown and gloves to prevent the spread of infection.

During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated it was important all facility staff followed the proper infection control protocols to prevent the spread of infection.

During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Standard Precautions (ESP), revised 1/2024, the P&P indicated the purpose of ESP was to prevent Multi-Drug-Resistant Organisms (MRDO, bacteria resistant to many antibiotics) in skilled nursing facilities. The P&P indicated ESP was an approach of targeted gown and glove use during high contact resident care activities. The P&P indicated gowns and gloves were to be worn while performing high contact tasks associated with the greatest risk for MRDO contamination of hands, clothes, and the environment, which included any care activity where close contact with the resident was expected to occur. The P/P indicated, Change gloves, as necessary during the care of a resident to prevent cross contamination from one body site to another (when moving from a dirty site to a clean one).

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d. During an observation on 04/10/2025 at 4:57 p.m., during medication pass, observed LVN 5 brought a rolling blood pressure machine to resident room. LVN 5 failed to sanitize the BP cuff before and between resident use.

During a concurrent observation and interview on 4/10/25 at 5:10 p.m , with LVN 5, LVN 5 stated she should sanitize the blood pressure cuff before and between resident use for infection control.

During an interview on 4/11/2025 at 1:28 p.m., with the IPN, IPN stated the staff are required to disinfect equipment's such as the BP cuff before and after use to prevent cross contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of the facility's policy and procedure (P&P) titled, Infection Control-DME dated 10/2011, the P&P indicated It is the policy of the facility to properly and routinely sanitize durable medical equipment Level of Harm - Minimal harm or (DME). When available, the manufacturer's instructions will be followed for cleaning non-critical care items. potential for actual harm In the absence of manufacturer's cleaning instructions, the following will be used to clean and disinfect these items between resident use: Residents Affected - Some 1.Bleach wipes or germicidal wipes will be used for DME after each use.

2.If any equipment has been potentially exposed to C-difficile (stool infection), a 1:10 bleach and water solution will be used to clean and sanitize. This solution should be allowed to remain on the item for 5 minutes.

3.It is the responsibility of the nursing personnel to properly and routinely sanitize DME after each use.

45269

5.During a concurrent observation and interview on 4/10/2025, at 9:03 a.m. with Maintenance Supervisor (MS), observed one plastic bag containing clean linen was torn and was on top of an uncovered laundry bin intended for clean linens and clothes located outside the facility. Observed two bags of dirty linens were on

the floor next to the large blue bins and cart where the clean linens were located. MS stated the staff should not leave the soiled bags on the floor next to clean laundry bins and laundry cart to prevent spread of infection. MS stated they used an outside company to do the laundry of the residents, and the clean laundry was placed on the large blue laundry bins outside the facility. MS stated the staff would empty the soiled linens in the storage area outside the facility across the clean area where the bags of clean linens are located.

During an interview on 4/10/2025, at 10:10 a.m. with CNA 2, CNA 2 stated the staff should not leave bags of soiled linens near the clean area where the blue clean laundry bins were located because of the risk of cross contamination and infection control.

During an interview on 4/11/2025, at 11:39 a.m. with the Director of Staff Development (DSD), the DSD stated the laundry bins for the soiled linens were in the left side and on the right side was the blue laundry bins containing the clean bags of linens outside the facility. The DSD stated the laundry blue bins store the clean linens and should be covered to prevent cross contamination that could lead to spread of infection. The DSD stated the two bags of soiled linens should not be placed or laid on the floor next to the clean laundry bin because they were soiled and can cause spread of infection. The staff should have placed the bags of soiled linen directly to the laundry bins intended for soiled linens.

During an interview on 4/11/2025, at 1:56 p.m. with the IPN, the IPN stated failed to observed and practiced proper handling and transporting of soiled linens could make residents sick in the facility and had the potential to cause cross contamination.

During an interview on 4/11/2025, at 2:48 p.m. with the DON, the DON stated that clean linens, and dirty linens should be separated when handling and transporting linens to prevent spread of infection among the residents and staff members.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of facility's policy and procedure (P&P) titled Infection Control-Laundry Services, revised 7/ 2019, the P&P indicated It is the responsibility of the facility to ensure all laundry was handled, stored, Level of Harm - Minimal harm or processed and transported in a safe and sanitary manner, regardless of where the laundry is processed. The potential for actual harm P& P indicated Dirty linen should be clearly separated from areas where clean linen is handled, and workflow should prevent cross contamination. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 45269 potential for actual harm Based on observation, interview and record review, the facility failed to ensure reach in freezer for frozen Residents Affected - Some vegetables and freezer for frozen meat products in the kitchen were maintained and kept in a safe and operating condition by failing to:

1. Follow their policy and procedure titled Freezer Storage regarding maintaining a temperature of 0-degree Fahrenheit (F- unit of measurement) or lower .

This failure had the potential to expose residents at risk for food-borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites).

Findings:

During an initial kitchen tour observation on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), DM verified

the internal thermometer of the reach in freezer for frozen vegetables was reading at 10 degrees Fahrenheit (F- unit of measurement) and the reach in freezer for meat products was reading at 24 degrees F. DM stated

the kitchen personnel just removed some food items from the freezers that was why the temperatures are not 0-degree F on both freezers.

During an interview on 4/8/2025, 2:15 p.m. with an unnamed technician (UT), the UT stated that they were called to fix the freezers around noontime today because the temperatures were high. Observed the freezer's temperature was 10 degrees F for frozen vegetables and freezer for frozen meat products was 18 degrees F.

During an observation on 4/9/2025, at 12:05 p.m. with DM, reach in freezer temperature for frozen vegetables was 10 degrees F. Observed the freezer was empty.

During an interview on 4/9/2025, at 12:10 p.m. and subsequent interview on 4/9/2025, at 1:17 p.m. with DM, DM stated he was aware the temperature of the freezer for the frozen vegetables was not maintained at 0-degree F or below since yesterday. DM stated he was monitoring the temperature of the freezer and was waiting for the temperature to go down to 0 degree but did not happen. DM stated the Registered Dietician (RD),and the Administrator (ADM) were aware the reach in freezer for vegetables was not maintaining its proper temperature. DM stated they threw away some of the frozen food items at around 9:00 a.m. today but

the kitchen used the vegetables from the non-working freezer for the stir fry vegetables for lunch. DM stated residents could be at risk for unsafe food because of the vegetables used for the stir fry vegetables were not properly stored in the freezer.

During a review of facility's Freezer Temperature Log for vegetables, the A.M. Temperature log of the freezer indicated a temperature of 10 degrees F on 4/9/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 During an interview on 4/9/2025, at 12:51 p.m. with Dietary Aide (DA 1), DA 1 stated the DM told him to throw away the vegetables , and some breads from the freezer around 9:00 a.m. today and at that time the Level of Harm - Minimal harm or temperature of the freezer was 10 degrees F. DA 1 stated the vegetables used for the stir fry for lunch came potential for actual harm from the freezer that was reading 10 degrees F. DA 1 stated the proper temperature to store frozen vegetables is 0 degree F to ensure freshness of food and to prevent bacterial growth that could place Residents Affected - Some resident at risk for food borne illness.

During an interview on 4/9/2025, at 12:50 p.m. with [NAME] (CK1), CK 1 stated the temperature of the freezer for the vegetables at around 4:00 a.m. was 10 degrees F. CK 1 stated that he pulled out broccoli, carrots, zucchini and cauliflower from the non-working freezer to prepare for the day's meal. CK 1 stated all

the vegetables that was served for lunch was from the non-working freezer. CK 1 stated residents could get sick from consuming the food if the vegetables were not stored properly in the freezer.

During an interview on 4/9/2025, at 1:46 p.m. with RD, RD stated the temperature log of the freezer might not be reliable because it all indicated the temperatures are 0-degree F and the situation that could be going

on for days. RD stated they should have discarded everything in the freezer because the facility does not know how long it had not been working. RD stated she is aware not all the food items stored in the non-working freezer was thrown away and was served for lunch today.

During an interview on 4/9/2025, at 2:24 p.m. with Maintenance Supervisor, MS stated he was made aware yesterday by the DM about the non-working freezer. MS stated they started emptying the food items in the freezer this morning and placed some of the food items in the other freezer. He said he would call the technician if the freezer needs repair and he does not do maintenance of the freezers.

During a telephone interview on 4/9/2025, at 2:14 p.m. with Administrator (ADM), ADM stated when the freezer's temperature was over zero despite maintenance, the kitchen personnel should have discarded the food items stored in the freezer. ADM stated residents could get food poisoning from consuming the food that came from the freezer.

During a review of facility's policy and procedure (P&P) titled Preventive Maintenance Policy dated 07/2023,

the P &P indicated the facility considers a Preventative Maintenance Program for all physical plant systems and equipment in all departments to eliminate and prevent unsafe environments.

During a review of facility's P&P titled Freezer Storage, the P&P indicated the freezer should be maintained at a temperature of 0-degree F and freezer should be recorded twice daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 055123

F-F842

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45269

Residents Affected - Few Based on interview and record review, the facility failed to identify and address one of four sampled residents (Resident 53) behavioral health needs by failing:

A. to ensure Brief Trauma Screening Questionnaire (tool used to assess an individual's potential exposure to traumatic events and their current PTSD symptoms and this tool is used to help identify individuals who may need further assessment or support for trauma) for Resident 53 who had a diagnosis of Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing

a traumatic event) was assessed and screened properly by social service personnel.

This failure had the potential for Resident 53 for not receiving appropriate care to meet his behavioral needs.

Findings:

During a review of Resident 53's Admission Record, the Admission Record indicated the resident was originally admitted on [DATE REDACTED] and was readmitted on [DATE REDACTED] to the facility with diagnoses that included PTSD, dementia( progressive state of decline in mental abilities), personal history of military service (a collection of information which permanently documents a service members career in the in the army, air forces and naval forces).

During a review of Resident 53's Minimum Data Set (MDS- a resident assessment tool) dated 2/15/2025, the MDS indicated the resident had severely impaired cognitive skills ( a significant decline in intellectual capacity and characterized by difficulties in memory, thinking, learning, and judgement affecting daily life activities) and required substantial/ maximal assistance (helper does more than half) with toileting hygiene, bathing, dressing and personal hygiene. The MDS indicated the resident had a diagnosis of PTSD.

During a review of Resident 53's Brief Trauma Questionnaire and Life Events Checklist( tool used to assess

an individual's history and experiences and these questionnaires can help identify individuals who may benefit from further assessment and treatment for trauma-related disorders like PTSD) dated 2/2/2025,the Brief Trauma Questionnaire and Life Events Checklist indicated the resident did not experience combat or exposure to a warzone in the military or as a civilian and had no history of traumatic events.

During a review of Resident 53's Psychosocial Assessment Form (tool used to collect comprehensive information about an individual's psychosocial, social and environmental factors to help understand resident needs )dated 2/4/2025, the Psychosocial Assessment Form indicated had a history of military service for two years.

During an interview on 4/11/2025, at 9:57 a.m. with Certified Nursing Assistant (CNA1), CNA 1 stated Resident 53 would yell suddenly because of pain. CNA1 stated she was not aware the resident had PTSD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 During an interview on 4/10/2025, at 1:38 p.m. with Licensed Vocational Nurse (LVN 4), LVN 4 stated the resident did not show any behavioral symptoms for PTSD and was not aware what could trigger resident's Level of Harm - Minimal harm or PTSD. potential for actual harm

During a concurrent interview and record review of Resident 53's Brief Trauma Questionnaire and IDT Care Residents Affected - Few Conference Summary dated 2/4/2025 with Director of Social Service (DSS), DSS confirmed the resident had PTSD as one of the diagnoses but did not know what could trigger resident's behavior for PTSD. DSS stated

the Brief Trauma Questionnaire did not indicate resident's history of military service or exposure to war. DSS stated Resident 53's Brief Trauma Questionnaire and Life Event Checklist did not identify resident's exposure to traumatic events like war because resident was not properly screened and assessed. DSS stated Resident 53 would not receive appropriate services that would address his PTSD, and the facility should be able to identify what could trigger Resident 53's PTSD so a plan of care could be created to manage his behavior.

During an interview on 4/11/2025, at 2:48 p.m. with Director of Nursing(DON), DON stated it's important to properly screen and identify residents who had PTSD to ensure necessary services and care will be provided to the residents. DON stated knowing what could trigger the behavior will help with the management and development of plan of care.

During a review of facility's policy and procedure (P&P) titled Trauma informed Care revised 1/2020, the P&P indicated the Social Service personnel will complete a Brief Trauma Questionnaire and Life Events Checklist that will serve as an assessment tool to determine if the resident had sustained a serious or traumatic life event. The P&P indicated the facility would have sufficient staff that would provide nursing and related services. The P &P indicated based on the comprehensive assessment will receive appropriate treatment and services to correct the assessed problem of a resident who displays or is diagnosed with a mental disorder or who has history of trauma and PTSD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 45269

Residents Affected - Some Based on observation, interview and record review, the facility failed to:

1. Ensure open bag of frozen sausages was stored properly in the freezer.

2. Ensure freezer temperature was maintained at 0-degree Fahrenheit (F-unit of measurement) while frozen vegetables were stored.

3. Ensure gloves were used by kitchen staff when serving cooked food during tray line.

4. Ensure proper donning of glove and handwashing was observed when the [NAME] switched tasks from tray line to prepare food in the microwave.

These failures had the potential to put residents at risk for food-borne illnesses ( any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and affect the quality of food.

Findings:

1.During an initial kitchen observation and interview on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), an open bag of frozen sausages was inside an open box. Observed the frozen sausages had ice crystals on the surfaces.DM stated the open bag of frozen sausages should be stored in a sealed plastic bag.

During an interview on 4/9/2025, at 1:30 p.m. with Registered Dietician (RD), RD stated open bag of frozen sausages not properly sealed can affect the quality of food. RD stated the kitchen staff should have transferred the frozen sausages in zip lock bag or tied the bag to preserve the moisture because the frozen food could dry out and can be exposed to bacteria.

During a review of facility's policy and procedure (P&P) titled Procedure for Freezer Storage undated, the P&P indicated to store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn (is a result of moisture loss from frozen food due improper packaging or storage).

2. During an initial kitchen tour observation on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), DM verified

the internal thermometer of the reach in freezer for frozen vegetables was reading at 10 degrees F and the reach in freezer for meat products was reading at 24 degrees F. DM stated the kitchen personnel just removed some food items from the freezers that's why the temperatures are not 0-degree F on both freezers.

During an interview on 4/8/2025, 2:15 p.m. with an unnamed technician (UT) in the kitchen, the UT stated that they were called to fix the freezers around noontime today because the temperatures were high. Observed the freezer's temperature was 10 degrees F for frozen vegetables and freezer for frozen meat products was at18 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an observation on 4/9/2025, at 12:05 p.m. with DM, reach in freezer temperature for frozen vegetables was 10 degrees F. Level of Harm - Minimal harm or potential for actual harm During a review of facility's recipe of stir-fry vegetables, the recipe indicated ingredients included assorted vegetables such as cauliflower, broccoli, squash, onions, zucchini and carrots and can use frozen or fresh. Residents Affected - Some

During an interview on 4/9/2025, at 12:10 p.m. and subsequent interview on 4/9/2025, at 1:17 p.m. with DM, DM stated he was aware the temperature of the freezer for the frozen vegetables was not maintained at 0-degree F or below since yesterday (4/8/2025). DM stated he was monitoring the temperature of the freezer and was waiting for the temperature to go down to 0 degree but did not happen yesterday. DM stated the Registered Dietician (RD),and the Administrator (ADM) were aware to reach in freezer for vegetables was not maintaining its proper temperature. DM stated they threw away some of the frozen food items at around 9:00 a.m. today but the kitchen used the vegetables from the non-working freezer for the stir fry vegetables that was served for lunch. DM stated residents could be at risk for unsafe food because of the vegetables used for the stir fry vegetables were not properly stored in the freezer.

During a review of facility's Freezer Temperature Log for vegetables, the A.M. Temperature log of the freezer indicated a temperature of 10 degrees F on 4/9/2025.

During an interview on 4/9/2025, at 12:51 p.m. with Dietary Aide (DA 1), DA 1 stated the DM told him to throw away the vegetables , and some breads from the freezer around 9:00 a.m. today and at that time the temperature of the freezer was 10 degrees F. DA 1 stated the vegetables used for the stir fry for lunch came from the freezer that was reading 10 degrees F. DA 1 stated the proper temperature to store frozen vegetables is 0 degree F to ensure freshness of food and to prevent bacterial growth that could place resident at risk for food borne illness.

During an interview on 4/9/2025, at 12:50 p.m. with [NAME] (CK1), CK 1 stated the temperature of the freezer for the vegetables at around 4:00 a.m. was 10 degrees F. CK 1 stated that he pulled out broccoli, carrots, zucchini and cauliflower from the non-working freezer to prepare for the day's meal. CK 1 stated all

the vegetables that was served for lunch was from the non-working freezer. CK 1 stated residents could get sick from consuming the food if the vegetables were not stored properly in the freezer.

During an interview on 4/9/2025, at 1:46 p.m. with RD, RD stated the temperature log of the freezer might not be reliable because it all indicated the temperatures are 0-degree F for several days and the situation could be going on for days. RD stated they should have discarded everything in the freezer because the facility does not know how long it had not been working. RD stated she was aware not all the food items stored in the non-working freezer was thrown away and was served for lunch today.

During an interview on 4/9/2025, at 2:24 p.m. with Maintenance Supervisor, MS stated he was made aware yesterday by the DM about the non-working freezer. MS stated they started emptying the food items in the freezer this morning and placed some of the food items in the other freezer. He said he would call the technician if the freezer needed repair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a telephone interview on 4/9/2025, at 2:14 p.m. with Administrator (ADM), ADM stated when the freezer's temperature was over zero despite maintenance, the kitchen personnel should have discarded the Level of Harm - Minimal harm or food items stored in the freezer. ADM stated residents could get food poisoning from consuming the food potential for actual harm that came from the freezer.

Residents Affected - Some 3. During a tray line observation on 4/8/2025, at 11:40 a.m. in the kitchen, cooked food items in trays were

on the steam table as the [NAME] (CK1) took temperatures of each cooked food items then proceeded to start preparing a plate for each resident. Observed CK 1 and another kitchen staff were scooping cooked food items from the trays to a plate without wearing gloves as another kitchen personnel called out the diet of

a resident.

During an interview on 4/9/2025, at 12:10 p.m. with CK 1, CK 1 stated kitchen personnel do not wear gloves when handling and serving cooked food during tray line.

During an interview on 4/9/2025, at 1:30 p.m. with RD, RD stated the kitchen staff should wear gloves when handling ready to serve and cooked food to prevent the risk of cross contamination (unintentional transfer of harmful bacteria from one surface or object to another).

4.During an observation on 4/9/2025, at 12:00 p.m. with CK 1, CK 1 wore a glove on the right hand without practicing hand washing first and brought a plate in the storage area to use the microwave. Observed CK 1 still wearing the glove on his right and continued serving in the lunch tray line without washing hands and removal of glove.

During an interview on 4/9/2025, at 12:10 p.m. with CK 1, CK 1 stated hand washing should be practiced every time he touched another food item and admitted he committed in not practicing hand washing when he switched tasks. CK 1 stated he should have removed his glove and washed hands before serving food in the tray line to prevent cross contamination which could cause food-borne illnesses to the residents.

During an interview on 4/9/2025, at 1:46 p.m. with RD, RD stated the cook should have removed his glove and washed his hands in between tasks then put on new pair of gloves before returning to serve food in the tray line. RD stated handwashing should be performed because of the risk of cross contamination between different objects like the microwave.

During an interview on 4/11/2025, at 2:48 p.m. with Director of Nursing (DON), DON stated not practicing handwashing in the kitchen could spread infection among the residents and staff. DON stated the facility had

a policy to maintain and keep the temperature of the freezers zero or below zero to ensure the food that will be consumed by the residents are safe to eat.

During a review of facility's P&P titled Food Handling undated, the P&P indicated the food will be prepared and served in a safe and sanitary manner. The P&P indicated Food and Nutrition Services personnel should never use bare hand contact with any foods , ready to eat or otherwise including food item preparation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a review of Food Code 2022 U.S. Food and Drug Administration ( a model document published by U. S. Food and Drug Administration that provides guidance for regulating food safety in a retail setting such as Level of Harm - Minimal harm or restaurants, groceries and institutions like Nursing Homes), the Food Code 2022 U.S. FDA indicated food potential for actual harm employees shall clean their hands immediately before engaging in FOOD preparation including before donning gloves to initiate a task that involves working with food and after engaging in other activities that Residents Affected - Some contaminate the hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45382

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure two of seven sampled resident's (Residents 14 and 19) medical records were accurately documented when:

a.Resident 14's Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, 12/11/2024, and 3/13/2025, inaccurately indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee) instead of the correct diagnosis of a left below knee amputation (BKA, surgical removal of a limb below the level of the knee involving the removal of the foot and ankle joint).

b.Resident 19's Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) physician's order inaccurately indicated for RNA to use a two-wheeled walker (mobility aid with wheels on the front two legs of the device) for walking exercises with Resident 19 instead of a platform walker (PFW, a type of walking assistive device with forearm supports to provide extra support during walking) as recommended by Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function).

These deficient practices had the potential to negatively impact the provision of necessary care and services, cause miscommunication among staff, cause a decline in function and safety concerns due to inappropriate use of assistive devices for mobility, and result in missed ROM assessments and opportunities to detect declines in joint range of motion (ROM, full movement potential of a joint).

Findings:

a.During a review of Resident 14's Admission Record, the Admission Record indicated Resident 14 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of

the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of

the nerves that can cause weakness, numbness, and burning pain).

During a review of Resident 14's Quarterly Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, the JMA indicated Resident 14 had moderate ROM limitations (50 to 75% motion) in both shoulders and minimal ROM limitations (75 to 100% motion) in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee joint). The section titled, Problem Summary, indicated Resident 14 had a left AKA, ROM limitations on the right leg, and no ROM changes (compared to previous assessment).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The Level of Harm - Minimal harm or MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching potential for actual harm assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body Residents Affected - Some dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury)

in both legs.

During a review of Resident 14's Annual JMA dated 12/11/2024, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle.

The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had a left AKA and ROM limitations in both shoulders and the right leg.

During a review of Resident 14's Quarterly JMA dated 3/13/2025, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle.

The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had no ROM changes.

During a concurrent observation and interview on 4/8/2025 at 12:40 pm, Resident 14 was lying in bed. Resident 14's right leg was fully straight and wrapped with an elastic bandage from the ankle to the knee. Resident 14's left leg was amputated below the level of the knee. Resident 14 was able to actively bend both knees and the right ankle minimally.

During a concurrent interview and record review on 4/10/2025 at 10:46 am, the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) stated the facility monitored for changes in joint ROM by annual JMAs completed by Rehab, quarterly JMAs completed by nursing, and by staff report.

The MDSC stated the MDSC and MDSA performed the quarterly nursing JMAs. The MDSC and MDSA stated the JMA assessment involved a detailed assessment of each resident's joints of both arms and both legs and indicated any ROM limitations and recommendations for services as needed to address any declines. The MDSC and MDSA reviewed Resident 14's JMAs and clinical record. The MDSC and MDSA confirmed the JMAs, dated 9/10/2024, 12/11/2024, and 3/13/2025, indicated Resident 14 had a left AKA and did not include assessments of Resident 14's left knee. The MDSC and MDSA confirmed Resident 14 had a left BKA, not a left AKA as was incorrectly documented on the JMAs. The MDSC and MDSA stated Resident 19's left knee ROM should have been assessed but was not and was unsure why it was overlooked for multiple JMAs. The MDSC stated it may have been mistakenly overlooked since the diagrams of the left knee and left ankle assessments were crossed out and incorrectly indicated Resident 14 had a left AKA. The MDSC stated inaccurate documentation could potentially result in missed opportunities to identify ROM declines, ROM decline, and inappropriate delivery of necessary care and services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a concurrent observation, interview, and record review on 4/10/2025 at 2:24 pm, Physical Therapist 1 (PT 1) assessed Resident 14's left leg. PT 1 asked Resident 14 to bend the left knee. Resident 14 bent the Level of Harm - Minimal harm or left knee minimally. PT 1 reviewed Resident 14's JMAs, dated 9/10/2024, 12/11/2024, and 3/13/2025, and potential for actual harm confirmed the JMAs incorrectly indicated Resident 14 had a left AKA, instead of the correct diagnosis of a left BKA. PT 1 stated it was important JMAs were completed accurately as incorrect documentation could affect Residents Affected - Some future assessments and services provided, lead to missed opportunities to identify declines, and result in ROM decline.

b. During a review of Resident 19's Admission Record, the Admission Record indicated Resident 19 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including a right hemiplegia (weakness to one side of the body) and difficulty walking.

During a review of Resident 19's MDS, dated [DATE REDACTED], the MDS indicated Resident 19 was cognitively intact.

The MDS indicated Resident 19 required substantial/maximal assistance with eating, partial/moderate assistance with walking, and was dependent for hygiene, bathing, toileting, dressing, and rolling to both sides. The MDS indicated Resident 19 had functional limitations in ROM in both arms.

During a review of Resident 19's RNA/Certified Nursing Assistant (CNA) Referral Form, dated 3/25/2025, the RNA/CNA Referral Form indicated for RNA to assist Resident 19 with walking exercises using a platform walker, every day, five times a week.

During a review of Resident 19's Physician Order Summary Report, the Physician Order Summary Report indicated a order, dated 3/25/2025, for RNA to assist Resident 19 with walking exercises using a two-wheeled walker, every day, five times a week.

During an observation on 4/8/2025 at 11:04 am, observed Resident 19 was seated in a power wheelchair in

the hallway. Resident 19's right hand was positioned in a fist and was unable to fully open the hand. The fingers of Resident 19's left hand was positioned with the thumb in hyperextension (the extension of a body part beyond it's normal limits) and the middle finger, ring finger, and small fingers bent into a fist.

During an observation of Resident 19's RNA session on 4/10/2025 at 8:45 am, in the hallway, Resident 19 was seated in a power wheelchair with a platform walker positioned in front of him. Resident 19 leaned forward, grabbed the handlebars of the platform walker, put his upper body weight onto the platform walker with both forearms, and stood up with Restorative Nursing Aide 1 (RNA 1) and Restorative Nursing Aide 2 (RNA 2)'s assistance. Resident 19 walked two laps around the facility with RNA 1 and RNA 2's assistance, sat down in power wheelchair, and remained seated in the hallway at the end of the session.

During a concurrent interview and record review on 4/10/25 at 9:40 am, RNA 1 and RNA 2 reviewed Resident 19's RNA orders and RNA/CNA Referral Form. RNA 1 confirmed Resident 19's RNA orders and RNA/CNA Referral Form instructions did not match. RNA 1 stated PT instructed the RNAs to use a platform walker when performing walking exercises with Resident 19 during RNA training. RNA 1 and RNA 2 stated Resident 19 would be unable to grasp the handles of a two-wheeled walker because the ROM of both of his hands were very limited. RNA 1 and RNA 2 stated the RNA order was written incorrectly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 33 055123 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055123 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a concurrent interview and record review on 4/10/2025 at 10:01 am, the Director of Rehabilitation (DOR) stated a licensed therapist determined the type of exercises and assistive devices a resident used for Level of Harm - Minimal harm or RNA services and established an RNA program for the RNAs to carry out. The DOR stated the licensed potential for actual harm therapist wrote the details of the RNA program on the RNA/CNA Referral Form and entered the RNA order into the electronic charting system. The DOR reviewed Resident 19's RNA order, dated 3/25/2025, and the Residents Affected - Some RNA/CNA Referral Form, dated 3/25/2025, and confirmed Resident 19's RNA order was written incorrectly.

The DOR stated the PT wrote for RNA to use a platform walker with Resident 19 for walking exercises on the RNA/CNA Referral Form and incorrectly wrote for RNA to use a two-wheeled walker for walking exercises on

the RNA order. The DOR stated if documentation was inaccurate, it could lead to RNAs providing the incorrect type of service, using an incorrect or unsafe device, and could result in the resident not being able to safely perform the activity or exercises prescribed.

During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated it was important documentation was accurate to ensure the staff had a correct assessment of a resident's status and provided the appropriate care and services. The DON stated if documentation was inaccurate, it could lead to inappropriate delivery of care and services, missed opportunities to identify declines or problem areas, safety concerns, and the development and implementation of an inaccurate care plan.

During a review of the facility's Policy and Procedure (P&P) titled, Documentation Principles, revised 2/2018,

the P&P indicated resident's clinical records shall be current and kept in detail consistent with good medical and professional practice based on the care provided for each resident. The P&P indicated entries must be accurate, timely, objective, specific, concise, legible, clear and descriptive.

CROSS REFERENCE TO