Ocean Ridge Post Acute

During an interview on 3/26/2026 at 3:23 p.m. with the Director of Nursing (DON), the DON stated any resident refusals for follow up appointments should be documented in the clinical record, care planned, discussed in an IDT meeting, and reported to the physician, nursing, and the resident's family.

The DON stated if the physician was not informed of a resident's refusal to follow up with orthopedics, the physician would be unable to follow up with the resident's care potentially resulting in a functional decline and lack of necessary treatment and services.

During a review of the facility's Policy and Procedure (P/P) titled, Change in a Resident's Condition or Status, revised 1/2026, the P/P indicated the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical condition and/or status.

The P/P indicated the nurse would notify the resident's attending physician or physician on call when there was a refusal of treatment or medications two or more consecutive times and if there was a need to alter the resident's medical treatment significantly.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

indicate a diagnosis of bipolar disorder but indicated Resident 12 was prescribed Depakote for Bipolar

diagnosis of Bipolar disorder prior to starting an antianxiety medication there would be potential that

3/26/2026 at 10:59 a.m., with the ADON, Resident 12's diagnosis information in the admission record and order summary report were reviewed.

The ADON stated Resident 12's diagnosis information in the admission record indicated bipolar disorder, the bipolar disorder diagnosis was added on 3/25/2026 and the order summary report indicated Resident 12 was prescribed Depakote for bipolar disorder on 1/6/2026 (78 days before Resident 12 was diagnosed with Bipolar).

The ADON stated the importance of having a diagnosis prior to starting any medication was to ensure the resident was assessed for any signs and symptoms or behaviors that may be treated or controlled by prescription medications.

The ADON stated if the resident did not have a diagnosis of Bipolar and was prescribed antianxiety medication there would be potential for the resident to experience negative side effects or the opposite effect the medication was intended to produce.During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use dated 2001, the P&P indicated .Adequate Indications for Psychotropic Medication Use.5.

Diagnosis alone does not necessarily warrant the use of psychotropic medication a. If a psychiatric diagnosis is part of the rationale for the use of psychotropic medication, there will be sufficient supporting documentation that the resident meets the criteria for that diagnosis (based on the current Diagnostic and Statistical Manual of Mental Disorders).

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

During a concurrent observation and interview on 3/23/2026, at 10:59 a.m., with Resident 19 in his room, Resident 19 was watching television in bed and missing upper front teeth were observed during the interview. Resident 19 stated, he lost his partial dentures while he was in General Acute Care Hospital (GACH) prior to admission to this facility. Resident 19 stated, his wife and he told the nursing staff that he had lost his partial dentures, but no one helped him. Resident 19 stated, it was painful to chew hard food items like chopped chicken or diced unripe melon.

During a concurrent interview and record review on 3/25/2026, 3:17 p.m., with the Minimum Data Set Nurse (MDSN), Resident 19's MDS section L-Oral/Dental Status, dated 11/17/2025 and 12/16/2026 was reviewed.

The MDS section L-Oral/Dental Status indicated, Resident 19 did not have any broken or loosely fitting full or partial dentures.

The MDS section L-Oral/Dental Status indicated, Resident 19 did not have any mouth or facial pain, discomfort or difficulty with chewing.

The MDSN stated, she was not aware of Resident 19's missing upper front teeth and she should have assessed the resident thoroughly before documenting in MDS.

The MDSN stated, the staff did not document Resident 19's dental status, and she thought there was no problem. MDSN stated, MDS coding should be done accurately because it affects the resident's plan of care and treatment.

During a concurrent interview and record review on 3/26/2026, at 2:46 p.m., with the Director of Nursing (DON), Resident 19's Dental Progress Note (DPN), dated 1/9/2026 was reviewed.

The DPN indicated, Resident 19 had broken teeth.

The DON stated, MDSN should have reviewed the DPN and should have assessed Resident 19's dental status thoroughly before documenting MDS.

The DON stated, all assessment in MDS should be coded correctly because this would affect resident's overall care and treatment negatively.

The DON stated, assessments should be accurate to get a clear representation of the residents.

During a review of the facility's Policy and Procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, the P&P indicated, Policy Interpretation and Implementation:

• Any person who completes any portion of the MDS assessment, tracking form, or correction

request form is required to sign the assessment certifying the accuracy of that portion of that assessment . 4.

The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident.

During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessments, revised 1/2026, the P&P indicated, Policy Interpretation and Implementation: 12.

Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. 13.

All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record.

The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

During a concurrent interview and record review on 3/25/2026, at 2:40 p.m., with the Director of Nursing (DON), Resident 11's Notice of Exempted Hospital Discharge, dated 1/19/2026 was reviewed.

The Notice of Exempted Hospital Discharge indicated, negative level I screening indicates a level II mental health evaluation is not required.

The Notice of Exempted Hospital Discharge indicated, if the individual remains in the nursing facility longer than 30 days, the facility must resubmit a new level I screening as a resident review on the 31st day.

The DON stated, new PASARR level I should have submitted on 2/19/2026 (31st day since admission of 1/19/2026) since Resident 11 was planned to stay longer than 30 days.

The DON stated, Resident 11 was admitted from General Acute Care Hospital (GACH) Psychiatric unite (provide 24/7 care for acute mental health disorders, focusing on safety, crisis stabilization, and medication management) due to SMI.

The DON stated, Resident 11 definitely needed mental health treatment and care.

The DON stated, the staff should have followed up with Level II evaluation to provide proper care and treatment.

During a review of Resident 11's Care Plan (CP) titled, Resident 11 has behavior problems, revised on 1/22/2026, the CP Goal indicated, Resident 11 would not have evidence of behavior problems by target date of 5/8/2026.

The CP Interventions indicated, administer medications as ordered, and monitor/document side effects and effectiveness.

During a review of the facility's Policy and Procedure (P&P) titled, PASARR, revised 1/2026, the P&P indicated, 1. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. c.

Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

meaningful to the resident, are the endpoint of an interdisciplinary process.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

During a concurrent interview and record review on 3/25/2026, at 10:10 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Ophthalmology Exam/Consult and Report, dated 10/14/2025 and 2/12/2026 were reviewed.

The Ophthalmology Exam/Consult and Report indicated, artificial tears regimen for dry eye treatment and Monocular Precautions such as control IOP, avoiding eye rubbing, and monitor for medications were recommended. RNS 1 stated, all the recommendations from the ophthalmologist should be carried out and reflected in Resident 45's care plan as interventions.During a concurrent interview and record review on 3/25/2026, at 3:35 p.m., with the Minimum Data Set Nurse (MDSN), Resident 45's Care Plan (CP) titled, Resident 45 has impaired visual function related to blindness on right eye, revised 7/14/2025 was reviewed.

The CP goal indicated, Resident 45 will maintain optimal quality of life within limitation imposed by visual function through 4/23/2026.

The CP Interventions indicated, identify factors affecting visual function and monitor signs and symptoms of acute eye problems.

The CP interventions indicated, there were no interventions for dry eyes and IOP control.

The MDSN stated, the staff failed to reflect ophthalmologist's recommendations to CP.

The MDSN stated, CP interventions should be revised and updated when there were recommendations from specialists including ophthalmologist to prevent further vision loss.

During an interview on 3/26/2026, at 2:53 p.m., with the Director of Nursing (DON), the DON stated, ophthalmologist's recommendations should be carried out as ordered after notifying the Primary Care Physician (PCP) and reflected to care plan as interventions to prevent further vision loss.

The DON stated, preserving vision loss was important to maintain Resident 45's quality of life.

The DON stated, the staff should have revised and updated care plan on 10/14/2025 and 2/12/2026 after ophthalmologist visits because ophthalmologists emphasized same recommendations twice in a row.During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2026, the P&P indicated, Policy Interpretation and Implementation: 8.

The comprehensive, person-centered care plan will: b.

Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 13.

Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

• The Interdisciplinary Team must review and update the care plan: a.

When there has been a significant change in the resident's condition.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

Follow-up, Social Services/Case Manager, revised 12/2008, the P/P indicated Social Services or

pertinent disciplines to arrange for services that have been ordered by the physician such as clinic

the resident's medical record and collaborate follow up appointments/referrals with the nursing staff or other pertinent disciplines to ensure appropriate follow-up was carried out.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

During a

out RNA exercises as ordered.

The DOR reviewed Resident 61's physician's orders, dated 3/16/2026,

DOR stated AAROM exercises were typically prescribed to residents who were unable to obtain full ROM on their own and needed the physical assistance of RNA or equipment to help move through the rest of the motion.

The DOR stated if an RNA order was written for AAROM exercises to both legs, it was expected that RNA would physically assist Resident 61 through his full available ROM in all joints of both legs because Resident 61 did not have the strength or ability to obtain full range independently.

The DOR stated if RNA did not provide Resident 61 with AAROM as ordered, it could result in ROM decline and contracture development.

During an interview on 3/26/2026 at 3:23 p.m. with the DON, the DON stated RNAs assisted residents in the facility with activities such as ROM exercises to ensure the residents maintained their current level of function and did not experience a functional decline after discharge from skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant).

The DON stated it was important for RNA to provide exercises as ordered to prevent potential declines in ROM function, and to avoid delaying a resident's progress towards goals.

During a review of the facility's Policy and Procedure (P/P) titled, Specialized Rehabilitative Services, revised 12/2009, the P/P indicated once a resident met his or her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either Nursing or Restorative Aides would implement to assure that the resident maintains his or her functional and physical status.

During a review of the facility's P/P titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents would not experience an avoidable reduction in ROM and residents with limited ROM would receive the treatment and services to increase and/or prevent a further decrease in ROM.

The P/P indicated the care plan would be developed by the interdisciplinary team based on comprehensive assessment and include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. CROSS-REFERENCE TO F-F726

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

During a concurrent interview and record review on 3/26/2026 at 11:28 a.m. with Physical Therapist 1 (PT 1), PT 1 reviewed Resident 51's therapy notes and confirmed Resident 51 was evaluated by PT services on 11/11/2025 and discharged from OT services on 2/5/2026. PT 1 stated Resident 51 was discharged from PT services because she reached her maximal functional level in mobility because of her orthopedic restrictions and refusal to wear the left leg CAM boot per physician's orders. PT 1 stated the purpose of a CAM boot was to protect the operated leg by removing pressure or force off the joint when transferring or walking. PT 1 stated PT 1 did not issue Resident 51 a FWW because it was unsafe. PT 1 stated Resident 51 tried walking one to two times during therapy but stopped and could not continue due to safety concerns and Resident 51's continued non-compliance with physician's orders. PT 1 stated Resident 51 was unsafe walking with a FWW without a left leg CAM boot and weightbearing through the left arm because it was against physician's orders and had the potential to disrupt Resident 51's healing process.

During a concurrent interview on 3/26/2026 at 3:23 p.m. with the Director of Nursing (DON), the DON stated PT and OT determined the level of assistance and type of device a resident needed to safely transfer and walk in the facility.

The DOR stated it was important for residents to follow physician's orders and therapy recommendations to prevent injury and accidents.

The DOR stated if Resident 51 was walking with a FWW that was not recommended by therapy without wearing a left leg CAM boot and weightbearing through the left arm against physician's orders, it could result in worsening of the fractures, harm, injury, and accidents.

During a review of the facility's Policy and Procedures (P/P) titled, Safety of Residents, revised 1/2026, the P/P indicated resident safety and supervision and assistance to prevent accidents were facility-wide priorities.

The P/P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

During a concurrent interview and record review on 3/24/2026 at 2:35 p.m. with the Director of Staff Development (DSD), the DSD stated the RNAs in the facility were Certified Nursing Assistants (CNA) with specialized training in RNA services.

The DSD reviewed Resident 61's physician's order, dated 3/16/2026, and confirmed Resident 61 had an RNA order for RNA to provide AAROM exercises to Resident 61's both legs.

The DSD stated AAROM meant the resident performed as much ROM as possible on his or her own and the RNA physically assisted the resident through the rest of the ROM.

The DSD stated if RNA did not know what AAROM exercises were and did not assist the residents with the appropriate ROM exercises as ordered, it could result in joint stiffness, ROM decline, and contractures.

During a concurrent interview and record review on 3/25/2026 at 1:27 p.m. with the Director of Rehabilitation (DOR), the DOR stated Rehab created the RNA programs based on a resident's needs.

The DOR stated RNAs were to carry out RNA exercises as ordered.

The DOR reviewed Resident 61's physician's orders, dated 3/16/2026, and confirmed Resident 61 had an RNA order for AAROM exercises to Resident 61's both legs.

The DOR stated AAROM exercises were typically prescribed to residents who were unable to obtain full ROM on their own and needed the physical assistance of RNA or equipment to help move through the rest of the motion.

The DOR stated it was important that RNAs were competent in the different types of ROM exercises as ordered to ensure they were appropriately addressing the resident's needs to prevent ROM decline and contracture development.

During an interview on 3/26/2026 at 3:23 p.m. with the Director of Nursing (DON), the DON stated RNAs assisted residents in the facility with activities such as ROM exercises to ensure the residents maintained their current level of function and did not experience a functional decline after discharge from skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant).

The DON stated RNAs must understand and demonstrate competency in the different types of range of motion exercises when providing RNA services to help prevent injuries, contracture development, and functional declines.During a review of the facility's Policy and Procedures (P/P), titled, Staffing, Sufficient and Competent Nursing, revised 1/2026, the P/P indicated the facility provided sufficient numbers of nursing staff with the appropriate skills and competency to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

During an interview on 3/26/2026 at 4:06 p.m., with the Director of Nursing (DON), the DON stated performance evaluations should be completed at least annually and as needed to ensure nurse aids are providing appropriate care, meeting expected performance, and identify strengths and areas for improvement.During a review of the facility's Policy and Procedure (P&P) titled, Performance Evaluation, revised January 2026, the P&P indicated a performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

indicated Resident 45 required moderate assistance from one staff for transfer, dressing, and

personal hygiene, toilet hygiene, eating.During a review of Resident 45's Care Plan (CP) titled,

Goal indicated, Resident 45 will maintain optimal quality of life within limitation imposed by visual function through by 4/23/2026.

The CP Interventions indicated arrange consultation with eye care practitioner as required.During a concurrent observation and interview on 3/23/2026, at 10:37 a.m., with Resident 45 in his room, Resident 45's right eye cornea (the transparent, dome-shaped outer layer at the very front of the eye) was cloudy and opaque (unclear). Resident 45 stated he lost vision in his right eye due to possible glaucoma (a group of eye diseases that damage the optic nerve often due to high fluid pressure inside the eye). Resident 45 stated, he became blind because he missed the optimal time to get treatment. Resident 45 stated he was not seen by his ophthalmologist as frequently as he wanted. Resident 45 stated, he was supposed to see ophthalmologist on 1/2026, but he was not seen by ophthalmologist until 2/2026. Resident 45 stated, he was worried about his left eye, and he asked the staff to arrange an appointment with ophthalmologist multiple times.During a concurrent interview and record review on 3/25/2026, at 1:37 p.m., with the SSD, Resident 45's Ophthalmology Exam/Consult and Report, dated 10/14/2025 was reviewed.

The Ophthalmology Exam/Consult and Report indicated, the ophthalmologist recommended follow up in three months.

The SSD stated that the follow up visit did not occur in three months and last visit was on 2/12/2026 that was over three months.

The SSD stated the staff should have followed through with the follow-up appointment in three months to ensure Resident 45 received the care and treatment as ophthalmologist recommended.

During an interview on 3/26/2026, at 2:53 p.m., with the Director of Nursing (DON), the DON stated, the SSD should be proactive with assisting the residents.

The DON stated it was SSD's responsibility to assist the residents with all aspects of their lives.

The DON stated that it was important to ensure specialty consultancy appointments were made in timely manner and follow through.

The DON stated the staff should have identified the residents' needs and arranged necessary services.During a review of the facility's Policy and Procedure (P&P) titled, Job Description: Social Service Director, revised 12/2025, the P&P indicated, The Social Services Director leads and oversees the delivery of social services to residents and their families, ensuring that each individual achieves the highest practicable level of physical, emotional, and psychosocial well-being .Essential Duties: Provide medically related social services so that the highest practicable physical, mental and psychosocial wellbeing of each resident is attained or maintained.

Assist in making outpatient appointments as ordered and schedule on-site ancillary patient services to include optometry, podiatry, dentistry and psychiatric services.During a review of the facility's Policy and Procedure (P&P) titled, Social Service, revised 1/2026, the P&P indicated, Policy Interpretation and Implementation: e.

Compiling and maintaining up-to-date information about community health and service agencies avail?able for resident referrals; f.

Making referrals to social service agencies as necessary or appropriate; g.

Maintaining appropriate documentation of referrals and providing social service data summaries to such agencies.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

Details for acetaminophen 500 mg was reviewed.

The order details dated 3/23/2026 indicated, Order

temp/lighting 3.

Reposition 4.

Toileting 5.

Music/TV 6.

Snacks 7.Warm/cold compress 8.

Breathing

and/or amount) per 24 hours, to include all acetaminophen (APAP) products, give 2 tablets = 1000 mg, QD (daily). LVN 3 stated Resident 32 complained of mild pain, so she (LVN 3) administered two tablets of acetaminophen 325 mg. LVN 3 stated the order for acetaminophen 500 mg did not clearly indicate a frequency which could increase the risk for acetaminophen overdose. LVN 3 stated the order indicated 2 tabs = 1000 mg, QD at the end of the order, but it was not clear if it was QD (daily) as needed or QD scheduled and first part of the order did not indicate a frequency for as needed dosing.During a review of Resident 32's MAR, dated 3/1/2026 to 3/23/2026, the MAR indicated two tablets each of separate orders of acetaminophen 325 mg and 500 mg which were documented as administered to Resident 32 on the following dates and times:1a.

Acetaminophen 500 mg, 2 tablets by mouth as needed for moderate to severe pain 4-10, administered on 3/12/2026 at 5:12 p.m.1b.

Acetaminophen 325 mg, 2 tablets by mouth every 6 hours as needed for mild pain 1-3, administered on 3/12/2026 at 8:30 p.m.2a.

Acetaminophen 500 mg, 2 tablets by mouth as needed for moderate to severe pain 4-10, administered on 3/13/2026 at 3:08 p.m.2b.

Acetaminophen 325 mg, 2 tablets by mouth every 6 hours as needed for mild pain 1-3, administered on 3/13/2026 at 8:30 p.m.3a.

Acetaminophen 325 mg, 2 tablets by mouth every 6 hours as needed for mild pain 1-3, administered on 3/23/2026 at 12:24 p.m. 3b.

Acetaminophen 500 mg, 2 tablets by mouth every 24 hours as needed for moderate to severe pain 4-10, administered on 3/23/2026 at 4:39 p.m.

During an interview on 3/24/2026 at 1:44 p.m. with the DON, the DON stated she (DON) corrected the order for Resident 32's acetaminophen 500 mg on 3/23/2026 so that it indicated instructions with frequency of every 24 hours as needed. DON stated she saw Resident 32's medical diagnoses and medical history of fatty liver disease and alcohol dependance. DON stated Resident 32 would be at risk for liver toxicity if acetaminophen was not administered appropriately.During a review of the facility's policy and procedure (P&P) titled, Medication Orders, dated 2001, the P&P indicated, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders.

The P&P indicated, 1.

Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. A placebo. orders.

The P&P indicated, PRN (as needed) Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration.

Example: Tylenol 500 mg by mouth 4 hours as needed for mild pain or temp greater than 101-degree Fahrenheit [( F) is a unit of temperature].During a review of the facility's P&P titled Administering Medications, dated 2001, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.

The P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

During a concurrent inspection and interview on [DATE] at 3:58 p.m. with the Assistant Director of Nursing (ADON) of Station 1 Medication Room, there were three bottles of vitamin C that were leaking, looked contaminated and/or deteriorated with brown colored spillage on and around the bottles on medicine cabinet's shelf. a.

Three bottles of vitamin C labeled with sealed clear plastic around their lids.The ADON stated although the vitamin C bottles were not expired, they (vitamin C bottles) did not look good to be administered.

During an interview on [DATE] at 1:57 p.m. with the DON, the DON stated the vitamin C bottles looked dirty and they could have been contaminated.

The DON stated there was a risk of contamination and would not be safe to administer to facility's residents.

The DON stated it was important to replace them (vitamin C bottles) with clean stock and the shelf area needed to be cleaned so that the other medications would not be contaminated.During a review of facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2001, the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls.

The P&P indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals.returning or destroying these items.

The P&P indicated, Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

The P&P indicated, Labeling of medications and biologicals. consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

Encounter Note, dated 1/12/2026, the Speech Therapy Treatment Encounter Note indicated, Resident

Report (OSR), date 3/25/2026, the OSR indicated, provide fortified (foods that have extra nutrients)

OSR indicated, consult with dental for oral hygiene with follow up and treatment as indicated was ordered on 11/10/2025.During a review of Resident 19's Care Plan (CP), dated from 11/10/2025 to 3/25/2026, the CP indicated, there was no CP for dental issues such as broken teeth or missing partial denture.During a review of the facility's Policy and Procedure (P&P) titled, Dental Services, revised 1/2026, the P&P indicated, Policy Statement: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

Policy Interpretation and Implementation: 1.

Routine and 24-hour emergency dental services are provided to our residents through: a contract agreement with a licensed dentist that comes to the facility monthly . 6.

Social services representatives will assist residents with appointments . 10. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

During a review of Resident 46's admission Record, the admission Record indicated the facility admitted Resident 46 on 3/18/2026 with diagnoses including end stage renal disease (permanent state of kidney failure where kidneys work at less than 10% capacity, failing to filter waste and extra fluid from the blood), heart failure (a chronic condition where the heart is too weak or stiff to pump blood efficiently) and arterial fibrillation (an irregular heartbeat).During a review of Resident 46's History and Physical (H&P), dated 3/20/2026, the H&P indicated, Resident 46 had the ability to understand and make decisions.\During a review of Resident 46's Minimum Data Set (MDS- a resident assessment tool), dated 3/25/2026, The MDS indicated Resident 46's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired.During a review of Resident 46's Arbitration Agreement dated 3/18/2026, the AA indicated Resident 46 signed the agreement.

During an interview on 3/25/2026 at 11:54 a.m. with Resident 46, Resident 46 stated he did not know what arbitration was. b.

During a review of Resident 91's admission Record, the admission Record indicated the facility admitted Resident 91 on 12/4/2025, and readmitted on [DATE] with normal pressure hydrocephalus (a brain condition where a special fluid builds up inside the brain), respiratory disorders (medical conditions that affect the lungs and airways) and immunodeficiency (a condition where the body's immune system is weakened).

During a review of Resident 91's H&P dated 12/5/2025, the H&P indicated whether Resident 91 had the ability to understand and make decisions.

During a review of Resident 91's MDS dated [DATE], The MDS indicated Resident 91's cognitive was moderately impaired.During a review of Resident 91's Arbitration Agreement dated 12/7/2025, the AA indicated Resident 91 signed the agreement.During an interview on 3/25/2026 at 11:52 a.m. with Resident 91, Resident 91 stated, the resident did not know what arbitration was.

During a concurrent interview and record review on 3/25/2026 at 12:15 p.m. with the admission Coordinator (AC), Resident 46's AA, dated 3/18/2026 and 91's AA, dated 12/7/2025 were reviewed.

The AC stated she asked Resident 46 and 91 if they understood the arbitration agreement, upon their response to yes, proceeded with signing without verifying their understanding.

The AC stated arbitration affects residents' rights, including waving the right to go to court.

During an interview on 3/26/2026 at 2:23 p.m. with the Director of Nursing (DON), the DON stated arbitration is a way to resolve disputes outside of court and singing the agreement gives up the right to proceed in court.

The DON stated it is important to ensure the residents or family understand what arbitration means and what the agreement involves before signing, and staff should verify understanding more thoroughly than by asking yes-or no questions.

During a review of the facility's Policy & Procedure (P&P) titled Binding Arbitration Agreements, dated November 2023, the P&P indicated after the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document:a. A signature alone is not sufficient acknowledgement of understanding.b.

The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement.

During an observation on 3/23/2026 at 10:09 a.m., a resident was observed accessing the clean linen cart located in front of room [ROOM NUMBER] without staff assistance.

During an interview on 3/24/2026 at 1:13 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated clean linen carts should only be accessed by facility staff to prevent the spread of bacteria. LVN 1 stated if clean linen carts were accessed by residents without assistance from the facility staff, there would be an increased risk for the spread of infection to other residents.

During an interview on 3/25/2026 at 2:14 p.m. with the Director of Nursing (DON), the DON stated the importance of making sure clean linen carts were only accessed by facility staff was to ensure the linens were not contaminated.

The DON stated if clean linen carts were accessed by residents without assistance from facility staff, there would be potential for an increased risk for cross contamination.

During a review of the facility's P&P titled Laundry and Bedding, Soiled dated 2001, the P&P did not indicate procedures for individuals who were designated to access clean linen carts. b.

During a concurrent observation and interview on 3/26/2026 at 3:07 p.m., with Laundry Aid (LA) 1, in the laundry area, multiple items were observed leaning against a wall above the hamper next to the washing machine, rather than being placed in a designated hamper or laundry chute. LA 1 stated the items included a resident's hat, soiled clothing, a shower blanket, medical devices; a wedge (essential positioning aids used to prevent pressure ulcers, facilitate turning, and improving comfort for immobile residents), a heel protector (a proactive medical devices designed to prevent pressure injuries in non-ambulatory residents by elevating the heel off the mattress), Intermittent pneumatic compression devices (leg squeezers-inflatable sleeves used in nursing homes to prevent blood blots and improve circulation in immobile residents), and used linens. LA 1 stated the observed items were used (soiled) it is not acceptable to store medical devices in the laundry area or to leave soiled linens outside a designated covered container.

During an interview on 03/26/2026 at 4:06 p.m. with the Director of Nursing (DON), the DON stated soiled linens and soiled medical devices must be kept in a designated container.

The DON stated these practices are necessary to prevent contamination and infection.

During a review of the facility's P&P titled Departmental (Environmental Services) – Laundry and Linen, dated January 2026, the P&P indicated to consider all soiled linen to be potentially infectious, all soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. If laundry chutes are used, only closed and leak-resistant bags will be put into the chute.

Loose items will not be placed in the laundry chute.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804

Based on interview and record review, the facility failed to maintain staff documentation of screening,

that could cause respiratory illness) vaccination status for all licensed practitioners.These failures had the potential to increase the risk of transmission of COVID-19 and other respiratory infections to all residents.Findings:During a concurrent interview and record review on 3/26/2026 at 9:59 a.m. with the Infection Preventionist (IP), the facility updated 2025-2026 COVID-19 vaccine acceptance/declination forms, undated, were reviewed.

The IP stated all individuals who provide care or have contact with residents, including the licensed practitioners, are considered staff, and the facility should encourage staff to receive COVID-19 immunization, including providing screening, education, offering vaccination, and maintaining documentation of vaccination status.

The IPN stated she did not document or maintain COVID-19 vaccination status for licensed practitioners including screening, education, offering.

The IP stated this is essential to prevent the spread of COVID-19 and other respiratory infections, and without tracking vaccination status, resident may be at risk of illness.

During an interview on 3/26/2026 at 4:06 p.m. with the Director of Nursing (DON), the DON stated the facility should maintain COVID-19 vaccination records for all staff, including licensed practitioners, to monitor vaccination status and reduce the risk of illness for residents.During a review of the facility's Procedure and Policy (PP) titled Coronavirus Disease (COVID-19)-Vaccination of Staff, dated January 2026, the P&P indicated staff are educated about benefits, risks, and potential side effects of the COVID-19 vaccine.

The P&P indicated Staff' means individuals who provide any care, treatment, or other services for the facility and/or its residents, regardless of clinical responsibility or resident contact, including employees, licensed practitioners, students, trainees, and volunteers.

056378 03/26/2026

Ocean Ridge Post Acute 3850 E.

Esther St.

Long Beach, CA 90804